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Date run 5/1812015 10:33:40AI SAN JCWIN COUNTY ENVIRONMENTAL HEA& DEPARTMENT Report*5021 <br /> Run by Pagel <br /> Facility Information as of 5/18/2015 <br /> Record selection Criteria: Facility ID FA0015125 <br /> Make changesicorrections 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 OW0014659 New Owner ID <br /> Owner Name GURM, MANDEEP S <br /> Owner DBA SUBWAY <br /> Owner Address 6111 RAYMOND CT <br /> STOCKTON, CA 95212 <br /> Home Phone 209-992-1415 <br /> Work/Business Phone 209-992-1415 <br /> Mailing Address 6111 RAYMOND CT <br /> STOCKTON, CA 95212 <br /> Care of GURM, MANDEEP <br /> FACILITY(FILE INFORMATION <br /> Facility ID/CERS ID FA0015125 10184869 <br /> Facility Name SUBWAY SANDWICHES <br /> Location 6283 N PACIFIC AVE <br /> Stockton, CA 95207 <br /> Phone 209-954-9502 x <br /> Mailing Address 6283 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of GURM, MANDEEP S <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 09746335 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GURM, MANDEEP <br /> Title <br /> Day Phone 209-954-9502 <br /> Night Phone 209-992-1415 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025949 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility f Account <br /> Account Name SUBWAY SANDWICHES (Circle One) <br /> Account Balance as of 5118/2015: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PRO522184 EE0006213-VIDAL PEDRA.ZA Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0528773 EE0000006-HAZA SAEED Active Y N A I D <br /> 3116-STORMWATER INSPECTION-FOOD PRO523041 EED000149-RAYMOND BORGES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533271 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,PHSYEHD 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 applicable Ordinance Codes andror Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date ! / Account out: Date f 1 <br /> COMMENTS: <br /> Invoice#: <br />