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Date run 4/2/2007 12:52:23PM SAN JOA^UIN COUNTY ENVIRONMENTAL HEAL"'I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/2/200, <br /> Record Selection Criteria. Facility ID FA0007026 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION — --�•.r..� <br /> Owner ID OW0010942 New Owner ID <br /> Owner Name NAGRA, JASWINDER S <br /> Owner DBA SUBWAY <br /> Owner Address 1746 EVERGREEN DR <br /> ROSEVILLE, CA 95747 <br /> Home Phone 916-772-6345 <br /> Work/Business Phone 209-366-2884 <br /> Mailing Address 14958 N THORNTON RD <br /> LODI, CA 95242 <br /> Care of JASWINDER NAGRA <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007026 / <br /> Facility Name SUBWAY <br /> Location 14958 N THORNTON RD <br /> LODI, CA 95242 <br /> Phone 209-366-2884 <br /> Mailing Address 14958 N THORNTON RD <br /> LODI, CA 95242 <br /> Care of JASWINDER NAGRA <br /> Location Code 99 - UNINCORPORATED AREA APN:05532023 <br /> BOS District 004 -VOGEL, KEN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0010106 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SUBWAY (Circle One) <br /> Account Balance as of 4/2/2007: $2200 <br /> \ (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PR0505824 EE0003361 -MARIBEL FLOHRSCHLnActive Y N A I D <br /> 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 <br /> 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: f� x" f- Date `l l Z l 0 1 Account out: _ Date <br /> COMMENTS: <br /> \\p hs-ehsql-nt\apps\envisions\reports\5021.rpt <br />