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Date mn 6/18/2015 11:41:01M SA AQUIN COUNTY ENVIRONMENTAL TH DEPARTMENT Report%So21 <br /> Pagel <br /> Run by <br /> Facility Information as of 6118/2015 <br /> [Record Selection Cnterm: Facility ID FA0001652 <br /> Make changeslcorrections 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 OW0000440 New Owner ID <br /> Owner Name HARMAN-LEX INC <br /> Owner DBA <br /> Owner Address 1537 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 916-689-2190 <br /> Mailing Address 8334 GERBER RD <br /> SACRAMENTO, CA 95828-3710 <br /> Care of OVERZET 225 INC <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0001652 10180793 <br /> Facility Name KFC HARMAN-LEX #225 <br /> Location 1537 N WILSON WAY <br /> STOCKTON, CA 95205-3119 <br /> Phone 209462-5929 x <br /> Mailing Address 8334 GERBER RD <br /> SACRAMENTO, CA 95828-3710 <br /> Care of HARMAN MGMT/SACRAMENTO REGION <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002-MILLER, KATHERINE Fax <br /> APN 11720028 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name OVERZET 225 INC <br /> Title MANAGER <br /> Day Phone 209-462-5929 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID: <br /> Account ID AR0001652 <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name KFC HARMAN-LEX #225 (Circle One) <br /> Account Balance as of 6/18/2015: $0.00 (Circle One) <br /> Transfer to ActiveAnacl <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status New Owner! Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO160512 EE0009488-JEFFREY WONG Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0529908 EE0000006-HAZA SAEED Active Y N A I D <br /> 2066-MILK DISPENSER PR0200235 EE0000370-WILLIAM MARCHESE Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533723 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator at agent of same,acknowledge that all site,anctor project specnc,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form. I also certJy that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and Stale andfor <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 /> Payment Type Check Number Received by <br /> EHD Staff: Date_/_/_Account out: Date <br /> COMMENTS: Invoice#: <br />