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Date*n 10/29/2014 8:29:57A SAN JO.JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> RurrIty Pagel <br /> Facility Information as of 10/29/2014 <br /> Record Selection Criteria: Facility ID FA0002367 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0006089 New Owner ID <br /> Owner Name DEEP S SAGOO INC <br /> Owner DBA ARBYS#7447 <br /> Owner Address 5642 HAVENCREST CIR <br /> STOCKTON, CA 95219 <br /> Home Phone 661-703-7298 <br /> Work/Business Phone 209-954-0929 <br /> Mailing Address 5642 HAVENCREST CIR <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0002367 10180915 <br /> Facility Name ARBYS#7447 <br /> Location 6248 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-954-0929 <br /> Mailing Address 6248 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of HARDEEPSINGH <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 08136002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HARDEEPSINGH <br /> Title PRESIDENT <br /> Day Phone 209-954-0929 <br /> Night Phone 661-703-7298 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004377 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ARBYS#7447 (Circle One) <br /> Account Balance as of 10/29/2014: $0.00 (Circle one) <br /> Transferto Activeflname <br /> Program/Element and Description Record ID Employee 1D and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PRO160890 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO527139 EE0000006-HAZA SAEED Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532149 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operalof or agent of same,acknowledge that all site,ender project specific.PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. l also ceddy that alloperations will be performed in accordance with all applicable Ordinance Codes angor Standards and State angor <br /> 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 Date <br /> Payment Type Check Number Received by <br /> RENS: Date_/_/_ Account out: Date <br /> COMMENTS: <br />