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Date ren 3/12/2015 9:47:22AR SAN JGVUIN COUNTY ENVIRONMENTAL HEAT` DEPARTMENT Reprn ttsozl <br /> Run by G �/ Paget <br /> Facility Information as of 3/12/2015 <br /> Record Selection Critena: Facility ID FA0019669 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 3 Z <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0016126 New Owner ID <br /> Owner Name IN N OUT BURGERS INC <br /> Owner DBA IN-N-OUT BURGER (LATHROP) <br /> Owner Address 4199 CAMPUS DR 900 <br /> IRVINE, CA 926122698 <br /> Home Phone Not Specified <br /> Work/Business Phone 628-813-8200 <br /> Mailing Address 4199 CAMPUS DR STE 900 <br /> IRVINE, CA 92612-2698 <br /> Care of ACCOUNTS PAYABLE <br /> FACILITY FILE INFORMATION C f <br /> Facility iD/CERS ID FA0019669 10167297 J <br /> Facility Name IN N OUT BURGER (LATHROP) <br /> Location 18240 HARLAN RD <br /> LATHROP, CA 95330 <br /> Phone 209-858-6810 x <br /> Mailing Address 4199 CAMPUS DR 9TH FLR <br /> IRVINE, CA 92612-2698 <br /> Care of IN-N-OUT BURGER INC. (LATHROP) <br /> Location Code Alt Phone <br /> BOS District 003 - BESTOLARIDES, STEVE Fax <br /> APN 19819031 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0035031 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name INN OUT BURGER (LATHROP) (Circle One) <br /> Account Balance as of 3/12/2015: $0.00 <br /> iCircle One) <br /> Transfer to Activellnactse <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0529832 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 1962-CaIARP PROGRAM 2 FACILITY PRO538878 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 1995-CaIARP FAC STATE SURCHARGE FEE PRO538884 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534603 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Nat all site,andor project specific,PHSIEHD 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 sector Standards and State ardor <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 /> Paymentheck Number Receive by <br /> REHS: y .LL 1(}'J�Date�//� 1'J� / j� Account out: "? Date <br /> Q�( ' <br /> COMMENTS:n w 460 <br /> 60 1 E !��i Z t/ ( G2e P[A <br /> PP Cal� W `7eAF1 <br />