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Date run 6/16/2015 3:18:17PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> z Paget <br /> Rtm by Facility Information as of 6/16/2015 <br /> Record Selection Criteria: Facility ID FA0022974 <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: 3 SSN/Fed Tax ID <br /> Owner ID OW0014770 New Owner ID <br /> Owner Name SINGH, GURPARTAP <br /> Owner DBA SUBWAY <br /> Owner Address 1135 PALOMAR CT <br /> TRACY, CA 95377 <br /> Home Phone 209-390-4050 <br /> Work/BusinessPhone 209-321-5656 <br /> Mailing Address 1135 PALOMAR CT <br /> TRACY, CA 95377 <br /> Care of SINGH, GURPARTAP <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022974 <br /> Facility Name SUBWAY G2325 INC <br /> Location 7503 W ELEVENTH ST <br /> TRACY, CA 95304 <br /> Phone 209-321-5656 <br /> Mailing Address 1135 PALOMAR CT <br /> TRACY, CA 95377 <br /> Care of SINGH, GURPARTAP <br /> Location Code 03-TRACY Alt Phone <br /> SOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SINGH, GURPARTAP <br /> Title <br /> Day Phone 209-321-5656 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0042138 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SUBWAY G2325 INC (Circle One) <br /> Account Balance as of 6/16/2015: $0.00 <br /> (c+mle one) <br /> Transfer to Activarinacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PR0540186 EE0001420-MELISSA NISSIM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHSIEHD hourly charges associated with this facility or: <br /> W billed to Qte party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State ander 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 DatePayment <br /> EHD StaffType ®Check Number ��l1/`l1� Account o Received Y Date <br /> `� �s Date <br /> COMMENTS: Invoice#: ;14--71-61 <br />