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Date run 6/18/2015 11:16:58AP SAI' AQUIN COUNTY ENVIRONMENTALE T DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/18/2015 <br /> Record Selection Criteria: Facility ID FA0002725 <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/Fed Tax ID <br /> Owner ID OW0010559 New Owner ID <br /> Owner Name H & R FOODS INC <br /> Owner DBA CHURCH'S CHICKEN #5773 <br /> OwnerAddress 6248 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Home Phone 661-703-7298 <br /> Work/Business Phone 209-475-1547 <br /> Mailing Address 6248 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of H & R FOODS INC <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002725 10180989 <br /> Facility Name CHURCHS CHICKEN #5773 <br /> Location 8023 WEST LN <br /> STOCKTON, CA 95210 <br /> Phone 209-475-1547 <br /> Mailing Address 6248 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of SINGH, HARDEEP <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 003 - BESTOLARIDES, STEVE Fax <br /> APN 08818007 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HARDY <br /> Title <br /> Day Phone 209-475-1547 <br /> Night Phone 661-703-7298 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004856 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name CHURCHS CHICKEN #5773 (Circle One) <br /> Account Balance as of 6/1812015: $0.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO160792 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1921 -HMBP-Reqular-Primary Location PRO513452 EE0000006-HAZA SAEED Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO511164 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PR0532066 Inactive 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 specife,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 andlor Standards and State andlor <br /> Federal Laws.. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 / <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date <br /> COMMENTS: Invoice#: <br />