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Date run 6/22015 10:23:20AM SANqkQUIN COUNTY ENVIRONMENTAL H TH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 6/2/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0002197 <br /> Make changesfcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 11 SSN/Fed Tax ID : <br /> Owner ID OW0001707 New Owner ID <br /> Owner Name PRB MANAGEMENT LLC <br /> Owner DBA TACO BELL <br /> OwnerAddress 4709 MANGELS BLVD <br /> FAIRFIELD, CA 945344175 <br /> Home Phone 707-864-2919 <br /> Work/Business Phone 707-864-2919 <br /> Mailing Address 4709 MANGELS BLVD <br /> FAIRFIELD, CA 94534-4175 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002197 10180889 <br /> Facility Name TACO BELL#2832 <br /> Location 3507 W HAMMER LN <br /> STOCKTON, CA 95219 <br /> Phone 209-477-9582 x <br /> Mailing Address 4709 MANGELS BLVD <br /> FAIRFIELD, CA 94534-4175 <br /> Care of PRB Management, LLC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 07118019 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SHERRY DANIEL <br /> Title <br /> Day Phone 707-557-1198 <br /> Night Phone 209-473-9759 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002208 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TACO BELL#2832 (Circle One) <br /> Account Balance as of 6/2/2015: $323.00 <br /> (Circle One) <br /> Program/Element and DescriptionRecord 10 Employee ID and Name Status Transfer to ActiveAnache <br /> New Owner! Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO160124 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO520699 EE0000006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO613430 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0511142 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532461 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 eni Standards and State andror <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date_/ / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />