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Dale run 7/31/2014 9:26:39AR SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report 05021 <br /> Run by Paget <br /> Facility Information as of 7/31/2014 <br /> Record Selection Cntena: Facility ID FA0012197 <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 OW0014830 New Owner ID <br /> Owner Name KAUR, RAJVIR <br /> Owner DBA <br /> Owner Address 9266 WHITEWATER LN <br /> STOCKTON, CA 95219 <br /> Home Phone 209478-2089 <br /> Work/Business Phone 209405-3555 <br /> Mailing Address 3622 poolo circle <br /> STOCKTON, CA 95212 <br /> Care of KAUR, RAJVIR <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012197 10184165 <br /> Facility Name SUBWAY/TCBY <br /> Location 5308 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-951-2527 x <br /> Mailing Address 5308 PACIFIC AVE#92 <br /> STOCKTON, CA 95207 <br /> Care of SUBWAY/TCBY <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 10224019 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SUBWAY/TCBY <br /> Title <br /> Day Phone 209-951-2527 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019614 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SUBWAY/TCBY (Circle One) <br /> Account Balance as of 7/31/2014: $-30.00 <br /> (Circle One) <br /> Transfer to ActivellnacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner.? Delete <br /> 1613-FOOD EST 501-1000 SO FT W/O SEATING PR0515505 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0530854 EE0000006-HAZA SAEED Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533067 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSrEHD hourly charges associated with this facility <br /> or adivity 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 endor Standards and State andor <br /> Federal taws. <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 /> RENS: Date_/ /_ Account out: Date <br /> COMMENTS: <br />