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Date run 12/20/2017 11:44:441 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/20/2017 <br /> Record Selection Criteria: Facility l0 FA0002754 <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 OW0021255 New Owner ID <br /> Owner Name Tiwana& Sons Inc <br /> Owner DBA SUBWAY <br /> OwnerAddress 5500 QUASHNICK RD <br /> STOCKTON, CA 95212 <br /> Home Phone 209-931-5631 <br /> Work/Business Phone 209-298-6629 <br /> Mailing Address 5500 QUASHNICK RD <br /> Stockton, CA 95212 <br /> Care of TIWANA, VERINDER <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002754 10180993 <br /> Facility Name Tiwana & Sons Inc dba Subway# 1955 <br /> Location 8046 WEST LN <br /> STOCKTON, CA 95210 <br /> Phone 209473-1678 x <br /> Mailing Address 5500 Quashnick Rd <br /> STOCKTON, CA 95212 <br /> care of Tiwana & Sons Inc <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 09057004 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CHIMA GURSHARAN <br /> Title <br /> Day Phone 209-956-5439 <br /> Night Phone 209-473-1628 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004395 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Vin Tiwana (Cirde One) <br /> Account Balance as of 12/20/2017: $0.00 <br /> (Circle One) <br /> Transfer to Ach wVInactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PRO160782 EE0078788-GEHANE FAHMYInactive <br /> 1919-HMBP-0O2 Only Food Facility PRO530855 EE0078788-GEHANE FAHMY Inactive <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534334 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSEHD 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 pertonned in accordance with all applicable Ordinance Codes andror Standards and State and'or <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 /> EHD Staff: Date_/ / Account out: Date <br /> COMMENTS: Invoice#: <br />