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Date ren 4/14/2015 3:01:43PR SAN JO AN COUNTY ENVIRONMENTAL HEAI ' DEPARTMENT Report#S021 <br /> Run by * Pagel <br /> Pagel <br /> Facility Information as of 4/14/2015 <br /> Record Selection Criteria: Facility ID FA0002006 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 5 SSN/Fed Tax ID <br /> Owner ID OW0009994 New Owner ID <br /> Owner Name WOMAR INC <br /> Owner DBA CARLSJR <br /> Owner Address 2643 3RD ST <br /> LIVERMORE, CA 94550 <br /> Home Phone 925-292-1024 <br /> Work/Business Phone 925-292-1024 <br /> Mailing Address 2643 3RD ST <br /> LIVERMORE, CA 94550 <br /> Care of WOMAR INC <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002006 10180849 <br /> Facility Name CARLS JR#495/7485 <br /> Location 2610 W MARCH LN <br /> STOCKTON, CA 95207 <br /> Phone 209-957-7311 x <br /> Mailing Address 2643 3RD ST <br /> LIVERMORE, CA 94550 <br /> Care of WOMAR INC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 002 - MILLER, KATHERINE Fax <br /> APN 11002002 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CARL KARCHER ENTERPRISE <br /> Title <br /> Day Phone 714-774-5796 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002014 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CARLS JR#495/7485 (CirueOne) <br /> Account Balance as of 4/14/2015: $323.00 <br /> (Cirde One) <br /> Transfer to Active/Inactve <br /> Progra"Element and Description Record ID Employee ID and Name Status New 01 Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO160484 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0521096 EE0000006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513366 EE0000000-HAZ MAT SJC OES InactivE Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511078 EE0000000-HAZ MAT SJC OES InactivE Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532059 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,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as Ore OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State and/or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: 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 Received by <br /> REHS: Date / / Account out: Date / / <br /> COMMENTS: <br />