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Date ren 7/8/2015 2:00:35PM SAN JOAQUIN CourITY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 7/8/2015 Record Selection Criteria: Facility ID FA0002982 Make changestcorrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0014517 Owner Name APG GROUP INC Owner DBA SUBWAY Owner Address 181 NABOR CT TRACY, CA 95377 Home Phone 209-835-7051 Work/Business Phone 209-836-1669 Mailing Address 181 NABOR CT TRACY, CA 95377 Care of KAUR, PARDEEP FACILITY FILE INFORMATION Facility ID/CERS ID FA0002982 Facility Name SUBWAY #12255 Location 1986 W ELEVENTH ST TRACY, CA 95376 Phone 209-836-1669 Mailing Address 1986 W ELEVENTH ST TRACY, CA 95376 Care of KAUR, PARDEEP Location Code 03 -TRACY Bos District 005 - ELLIOTT, BOB APN 23402011 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name KAUR, PARDEEP Title Day Phone 209-836-1669 Night Phone 209-835-7051 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0002544 Mail Invoices to Facility Account Name SUBWAY #12255 Account Balance as of 7/8/2015: $0.00 SSN /Fed Tax ID New Owner ID : Alt Phone Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1624 - RESTAURANT/BAR 21-50 SEATS PRO163349 EE0001420 - MELISSA NISSIM Active Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: Date $25.00 = Amount Paid Date Amount Paid Date Date Received by Account out: Date Invoice #: