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Date mn 6/17/2015 10:17:35A1 SA#AQUIN COUNTY ENVIRONMENTAL IWLTH DEPARTMENT Report r15021 <br /> Run by Pagel <br /> Facility Information as of 6/17/2015 <br /> Record Selection Criteria: Facility ID FA0002754 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 4 SSN/Fed Tax ID <br /> Owner ID OW0003482 New Owner ID <br /> Owner Name Gus Chima <br /> Owner DBA <br /> OwnefAddress 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/CERS ID FA0002754 10180993 <br /> Facility Name SUBWAY SANDWICHES & SALADS <br /> Location 8046 WEST LN <br /> Stockton, CA 95210 <br /> Phone 209-473-1678 x <br /> Mailing Address 1626 BENNINGTON CT <br /> STOCKTON, CA 95209 <br /> Care of GURSHARAN S CHIMA <br /> Location Code 01 -STOCKTON Alt Phone <br /> SOS District 002-MILLER, KATHERINE Fax <br /> APN 09057004 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CHIMAGURSHARAN <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 Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SUBWAY SANDWICHES&SALADS (CiroleOne) <br /> Account Balance as of 6/17/2015: $0.00 <br /> (Circle One) <br /> Transfer to AcgvelnacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1624- STAURANT/BAR 21-50 SEATS PRO160782 EE0009488-JEFFREY WONG Active Y N A I D <br /> 19 HMBP-Regular-Primary Location PR0530855 EE0000006-HA7A SAEED Active Y N A I D <br /> SC-ELECTRONIC REPORTING STATE SURCHARGI PR0534334 Inactive Y N A I D <br /> BILLING end COMPLIANCE ACKNOWLEDGEMENT: I,the md.rsigned owner,operator or agent or same,acknowledge that all site,ansor project specRc,PHSIEHD 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 anclor Standards and State ands <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date lI Account out: Date_Il_ <br /> COMMENTS: Invoice#: <br />