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Date Run by 7/6!2015 8:35:37AM SAN JOAQUIN C04INTY ZNVIRONMENTAL HEALTH DEPARTMENT Report #5021 Pagel Facility Information as of 7/6/2015 Record Selection Criteria: Facility ID FA0014851 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0011855 Owner Name SANDHU ENTERPRISE LLC Owner DBA QUIZNOS SUB OwnerAddress 209 E LOUISE AVE Phone LATHROP, CA 953308631 Home Phone 209-604-6859 Work/Business Phone 209-853-1380 Mailing Address 209 E LOUISE AVE Location Code LATHROP, CA 953308631 Care of SANDHU, BILL FACILITY FILE INFORMATION Facility ID / CERS ID FA0014851 Facility Name QUIZNOS SUB Location 127 SPRECKLES AVE MANTECA, CA 95336 Phone 209-923-4099 Mailing Address 127 SPRECKLES AVE MANTECA, CA 95336 Care of BILL SANDHU Location Code 04 - MANTECA Bos District 005 - ELLIOTT, BOB APN 22120035 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name BILL & NINA SANDHU Title OWNER Day Phone 209-923-4099 Night Phone 209-604-6859 Cell ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0025354 Mail Invoices to Facility Account Name QUIZNOS SUB Account Balance as of 7/6/2015: $0.00 Make changesicorrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1624 - RESTAURANT/BAR 21-50 SEATS PR0521864 EE0004589 - KADEANNE LINHARES Active Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS Date $25.00 = Amount Paid Date ! /_ Amount Paid Date / / Date Received by Account out: Date Invoice #: