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Date run 6/15/2015 4:01:14PR SAN J&UIN COUNTY ENVIRONMENTAL HEOH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 6115/2015 <br /> Record Selection Criteria: Facility ID FA0018337 <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: 1 SSN 1 Fed Tax ID <br /> Owner ID OW0015057 New Owner ID <br /> Owner Name Rafael Armenta. <br /> Owner DBA EL POLLO LOCO _ <br /> Owner Address 2155 W MARCH LN 1A <br /> STOCKTON, CA 95207-6420 <br /> Home Phone 209-527-2498 <br /> Work/Business Phone 209-527-2498 <br /> Mailing Address 1202 Tully Rd, Ste C <br /> Modesto, CA 95350 <br /> Care of ARMENTA, RAFAEL (PRESIDENT) <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0018337 10414621 <br /> Facility Name EI Polio Loco#3580 <br /> Location 1730 E Yosemite Ave <br /> Manteca, CA 95336 <br /> Phone 209-527-2498 X <br /> Mailing Address 1202 Tully Rd, Ste C <br /> Modesto, CA 95350 <br /> care of Nor-Cal Chicken, Inc. <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 209_239-0100 <br /> Night Phone 209-543-1592 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032318 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name Cesar Rivera (Circle One) <br /> Account Balance as of 611512015: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgranVElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PR0527052 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0540201 EE0000006-HAZA SAEED Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSlEHO 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 ail operations will be performed in accordance with all applicable Ordinance Godes and/or 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 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 I Account out: Date 1 1 <br /> COMMENTS: <br /> Invoice#: <br />