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Date run 6/1/2015 9:37:04AM SAN UIN COUNTY ENVIRONMENTAL HE10H DEPARTMENT Report k5021 Run by Pagel Facility Information as of 6/1/2015 Record Selection Criteria: Facility ID FA0002373 Make changes/corrections in RED ink. INFORMATION CHANGE(date) OWNERSHIP CHANGE(date) OWNER FILE INFORMATION Number of facilities for this owner: 11 SSN/Fed Tax ID Owner ID OW0001707 New Owner ID Owner Name PRB MANAGEMENT LLC Owner DBA TACO BELL Owner-Address 4709 MANGELS BLVD FAIRFIELD, CA 945344175 Home Phone 707-864-2919 Work/Business Phone 707-864-2919 Mailing Address 4709 MANGELS BLVD FAIRFIELD, CA 94534-4175 Care of FACILITY FILE INFORMATION Facility ID/CERS ID FA0002373 10180917 Facility Name TACO BELL#480 Location 627 N WILSON WAY STOCKTON, CA 95205 Phone 209-466-1328 x Mailing Address 4709 MANGELS BLVD FAIRFIELD, CA 945344175 Care of PRB Management, LLC Location Code 01 -STOCKTON Alt Phone BOB District 001 -VILLAPUDUA, CARLOS Fax APN 15109506 Entail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name MAKAWANA, DEPAK-DIST MGR Title Day Phone 209-929-9002 Night Phone 209-929-9002 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0002379 NewAccount ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account Account Name TACO BELL#480 (Circle One) Account Balance as of 6/1/2015: $0.00 (Circle One) Transfer to Activefinactve Program/Element and Description Record ID Employee ID and Name Status New Owner' Delete 1623-RESTAURANT/BAR 1-20 SEATS PRO160543 EE0008999-LEYNA HUYNH Active Y N A I D 1921 -HMBP-Regular-Primary Location PRO520698 EE0000006-HAZA SAEED Active Y N A I D 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513429 EE0000000-HAZ MAT SJC OES Inactive Y N A I D 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO511141 EE0000000-HAZ MAT SJC OES Inactive Y N A I D ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533085 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander 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 andor Standards and State ands' Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: '$25.00= Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: Date_/ /_ Account out: Date COMMENTS: Invoice#: