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Date run 6/20/2016 3:38:14PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/20/2016 <br /> Record Selection Criteria: Facility ID FA0002906 <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: 7 SSN/Fed Tax ID <br /> Owner ID OW0018824 New Owner ID <br /> Owner Name Don Schrader <br /> Owner DBA <br /> Owner Address 4502 GEORGETOWN PL 100 <br /> STOCKTON, CA 95207 <br /> Home Phone 209-478-0234 <br /> Work/Business Phone 209-938-1238 l <br /> Mailing Address 4502 Georgetown Place <br /> Stockton, CA 95207 <br /> Care of REDARHCSINC <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0002906 10181015 <br /> Facility Name MCDONALDS#11159 <br /> Location 5308 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-478-0234 x <br /> Mailing Address 4502 GEORGETOWN PL #100 <br /> STOCKTON, CA 95207 <br /> Care of Don Schrader <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002- MILLER, KATHERINE Fax <br /> APN 10224019 EMall: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name REDARHCS MANAGEMENT COMPA <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002467 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name MCDONALDS#11159 (Circle One) <br /> Account Balance as of 6/20/2016: $300.00 <br /> (Circle One) <br /> Transfer to Active#nacive <br /> Progrorn Element and Description Record ID Employee ID and Name Status New Owner? �Delete <br /> 1613-FOOD EST 501-1000 SQ FT W/O SEATING PRO162527 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A /) D <br /> 1919-HMBP-0O2 Only Food Facility PRO520984 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A T D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517643 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO517644 EE0000149-RAYMOND BORGES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533111 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 specigF PHSEHO hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER on this form Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State ands <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 Tye Check Number Received b <br /> EHD Staff �.L��a-t�: '�-f�,'�ililir.P/I�GN;'r Date l '717/ le a Account out: Date <br /> COMMENTS: ( Cy1/ <br /> IRVOICe#: <br /> Uta-r 4OL-) Lli aS <br />