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Date run 5/28/2015 11:39:36AP SAN JUIN COUNTY ENVIRONMENTAL HEOH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 5/28/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0007021 <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: 71 SSN/Fed Tax ID : <br /> Owner ID OW0001707 New Owner ID <br /> Owner Name PRE MANAGEMENT LLC <br /> Owner DBA TACO BELL <br /> OwnerAddress 4709 MANGELS BLVD <br /> FAIRFIELD, CA 945344175 <br /> Home Phone 707-864-2919 <br /> Work/Business Phone 707-864-2919 <br /> Mailing Address 4709 MANGELS BLVD <br /> FAIRFIELD, CA 94534-4175 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0007021 10182165 <br /> Facility Name TACO BELL#17155 <br /> Location 201 NORTHGATE DR <br /> MANTECA, CA 95336 <br /> Phone 209-239-2102 x <br /> Mailing Address 4709 MANGELS BLVD <br /> FAIRFIELD, CA 945344175 <br /> Care of PRB Management LLC <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 21619007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TACO BELL <br /> Title <br /> Day Phone 209-239-2102 <br /> Night Phone 707-557-1198 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0010100 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TACO BELL#17155 (Circle One) <br /> Account Balance as of 5/28/2015: $323.00 <br /> (Circle One) <br /> Program/Element and Desorption Rerord ID Em to ee ID antl Name Transfer to ActiveAnactve <br /> Employee Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO605818 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0520690 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513420 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0511132 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0531763 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHO hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State ander <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 /> EHD Staff: Date / / Account out: Date_/ I_ <br /> COMMENTS: <br /> Invoice#: <br />