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Date run 7/30/2015 4:32:02PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by It Pagel Facility Information as of 7/30/2015 Record Selection Criteria: Facility ID FA0000452 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0000372 Owner Name DHALIWAL, CHARANJIV Owner DBA POPEYES OwnerAddress 2190 MERIDIAN PARK BLVD Phone CONCORD, CA 94520 Home Phone 925-446-6806 Work/Business Phone Not Specified Mailing Address 2190 MERIDIAN PARK BLVD #G Location Code CONCORD, CA 94520 Care of DHALIWAL, CHARANJIV FACILITY FILE INFORMATION Facility ID / CERS ID FA0000452 Facility Name POP EYES #11833 Location 612 E KETTLEMAN LN 1625 - RESTAURANT/BAR 51-100 SEATS LODI, CA 95240 Phone 916-583-2345 Mailing Address 2190 MERIDIAN PARK BLVD #G 1921 - HMBP-Reqular-Primary Location CONCORD, CA 94520 Care of DHALIWAL, CHARANJIV Location Code 02 - LODI Bos District 004 - WINN, CHARLES APN 06206041 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name DHALIWAL, CHARANJIV Title EE0000000 - HAZ MAT SJC OES Day Phone 916-583-2345 Night Phone 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 1 SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0000451 Mail Invoices to Facility Mail Invoices to: Account Name POPEYES #11833 Account Balance as of 7/30/2015: $0.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1625 - RESTAURANT/BAR 51-100 SEATS PRO161805 Active Y N D 1921 - HMBP-Reqular-Primary Location 724 HAZ MAT SJC OE iEEiOOOOF37O Inactive Y N A I �I D 2066 - MILK DISPENSER 00239 WILLIAM MARCHESE Inactive Y N I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513466 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0511178 EE0000000 - HAZ MAT SJC DES Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror project specific, PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: Date * $25.00 = Amount Paid Date Amount Paid Date Date Received by Account out: 141�> Date 3 / Invoice #: