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Date run 712412017 2:46:31PN SAN JOAQUIN COUNTY ENVIRONMENTAL.. HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/24/2017 <br /> Record Selection Criteria: Facility ID FA0014826 <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 1 Fed Tax ID <br /> Owner ID OW0003482 New Owner ID <br /> Owner Name Gus Chima <br /> Owner DBA <br /> Owner Address 1626 BENNINGTON CT <br /> STOCKTON, CA 95209 <br /> Home Phone 209-956-5439 <br /> Work/Business Phone 209-601-1434 <br /> Mailing Address 1626 Bennington ct <br /> stockton, CA 95209 <br /> Care of CHIMA, GURSHARAN S <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0014826 10184803 <br /> Facility Name SUBWAY SANDWICHES <br /> Location 3706 E HAMMER LN STE 4B <br /> STOCKTON, CA 95212 <br /> Phone 209-473-4233 x <br /> Mailing Address 1626 BENNINGTON CT <br /> STOCKTON, CA 95209 <br /> Care of GURSHARAN CHIMA <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOIS District 002 - MILLER, KATHERINE Fax <br /> APN 13002005 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GURSHARAN CHIMA <br /> Title <br /> Day Phone 209-473-4233 <br /> Night Phone 209-601-1434 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025293 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility I Account <br /> Account Name SUBWAY SANDWICHES (Circle One) <br /> Account Balance as of 712412017: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PR0521831 EE0009488-JEFFREY WONG Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PRO522274 EE0009488-JEFFREY WONG Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531503 Inactiv€ Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENTS I,the undersigned owner,operator or agent of same.acknowledge that all site.ands project specific.PHS/l 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 appPieadle Ordinance Cedes andlor Standards and State andlcr <br /> Federal Laws- <br /> APPLICANT'S SIGNATURE: Date I 1 <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date I I <br /> COMMENTS: <br /> Invoice#: <br />