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Date mn' 2/20/2013 11:14:48AI SAN JO�UIN COUNTY ENVIRONMENTAL HEA/ I DEPARTMENT Report#5021 <br /> Ruoby ..� Pagel <br /> Facility Information as of 2/20/2013 <br /> Record Seledion Criteria: Facility ID FA0000438 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000362 New Owner ID <br /> Owner Name JEANELL INC (TACO BELL) <br /> Owner DBA TACO BELL <br /> Owner Address 801 S HAM LN STE M <br /> LODI, CA 952427502 <br /> Home Phone 209-334-0636 <br /> Work/Business Phone 209-369-5566 <br /> Mailing Address 801 S HAM LN STE M -�-'�— <br /> LODI, CA 952427502 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000438 <br /> Facility Name TACO BELL#3944 <br /> Location 608 W LODI AVE <br /> LODI, CA 95240 <br /> Phone 209-369-6656 <br /> Mailing Address 801 S HAM LN STE M <br /> LODI, CA 95242 LiJb9.S71F2 3�/_ <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 03319032 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FRED LEWIS <br /> Title <br /> Day Phone 209-368-5606 <br /> Night Phone 209-369-5566 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000437 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TACO BELL#3944 (Circle One) <br /> Account Balance as of 2/20/2013: $290.00 <br /> (Circle One) <br /> Transfer to Adivellnactve <br /> ProgranyElement and Description Record lD Employee ID and Name Status New Omer? Delete <br /> -RESTAURANT/BAR 51-100 SEATS PRO162426 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> 1921 HMBP-Regular-Primary Location PR0520706 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> -HAZ MAT BUSINESS PLAN AUTHORIZATI01PR0513443 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0511155 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO533607 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> 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" <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: �- A#-exca Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receive <br /> REHS: Date /_/_ Account out: Date <br /> COMMENTS: <br />