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Date run 2/26/2013 3:42:24PN SAN JO SAN COUNTY ENVIRONMENTAL HEAI DEPARTMENT Report#5021 <br /> Paget <br /> Run by Facility Information as of 2/26/2013 <br /> Record Selection Criteria: Facility ID FA0012236 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0009485 New Owner ID <br /> Owner Name KELLEY, JOE N II <br /> Owner DBA KELLEY BROS BREWING CO <br /> Owner Address 6825 ZERILLO DR <br /> RIVERBANK, CA 95367 <br /> Home Phone 209-604-6574 <br /> Work/Business Phone Not Specified <br /> Mailing Address 6825 ZERILLO DR <br /> RIVERBANK, CA 95367 <br /> Care of JOE N KELLEY II <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012236 <br /> Facility Name KELLEY BROS BREWING CO <br /> Location 112 E YOSEMITE AVE i <br /> MANTECA, CA 95336 <br /> Phone 209-825-1727 <br /> Mailing Address PO BOX 2466 <br /> MANTECA, CA 953361165 <br /> care of KELLEY BROS BREWING CO <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN 22102033 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KELLEY BROS BREWING CO <br /> Title <br /> Day Phone 209-825-1727 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019762 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KELLEY BROS BR ING CO (Circle One) <br /> Account Balance as of 2/26/2013: $350.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgranvElemem and Description Record ID Employee ID and Name Status New Omer? Delete <br /> RESTAURANT/BAR 101 +SEATS PRO515586 EE0003474-CHANDRA OM Inactive Y N A �I D <br /> 1921 HMBP-Regular-Primary Location PR0522268 EE0002474-MICHAEL PARISSI Active Y N A C�1;D <br /> -HAZ MAT BUSINESS PLAN AUTHORIZATIOPPR0517788 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0517789 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHrPR0533982 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent d same,aclmowladge that all site,andor project speafic.PHSIEHD hourly charges associated with this facility <br /> or adiviywill W billed to the party identified as the OWNER on thisform I also cerfiy that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Type Check Number Received y <br /> REHS: Date ! / Account out: Date <br /> COMMENTS: �� n 'q-� <br />