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Date run 512012015 11:44:18AF SAN JUIN COUNTY ENVIRONMENTAL HE4W DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/20/2015 <br /> Record selection Criteria: Facility ID FA0016066 <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: 4 5SN/Fed Tax ID <br /> Owner ID OW0005335 New Owner ID <br /> Owner Name IN N OUT BURGER INC <br /> Owner DBA <br /> OwnerAddress 13502 HAMBURGER LN <br /> BALDWIN PARK, CA 91706 <br /> Home Phone 626-813-8200 <br /> Work/Business Phone 949-509-6300 <br /> Mailing Address 4199 Campus Drive <br /> Irvine, CA 92612 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016066 10185075 _ <br /> Facility Name IN N OUT BURGER#191 <br /> Location 1490 E YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Phone 626-813-8200 x <br /> Mailing Address 4199 CAMPUS DR 9TH FLR <br /> IRVINE, CA 92612 <br /> Care of IN-N-OUT BURGER#191 <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 22120063 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BOB LANG JR <br /> Title <br /> Day Phone 626-813-8200 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0028035 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account <br /> Account Name IN N OUT BURGER#191 (Circle One) <br /> Account Balance as of 5/20/2015: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO523857 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> 1921 -HMBP-Reqular-Primary Location PRO526239 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SU'RCHARGI PRO532589 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEH❑hourly charges associated with this facility <br /> 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 andlor standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date ! 1 <br /> COMMENTS: <br /> Invoice#: <br />