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Date mn j 11/1342020 2:33:29P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/13/2020 <br /> Record Selection Criteria: Facility ID FA0023294 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 7 SSN/Fed Tax ID <br /> Owner ID OW0003612 New Owner ID <br /> Owner Name Tiwana & Sons Inc <br /> Owner DBA SUBWAY <br /> OwnerAddress 5500 QUASHNICK RD <br /> STOCKTON, CA 95212 <br /> Work/Business Phone 209-298-6629 <br /> Alternative Phone 209-931-5631 <br /> Mailing Address 5500 QUASHNICK RD <br /> STOCKTON, CA 95212 <br /> Care of TIWANA, AMRITPAL <br /> FACILITY FILE INFORMATION APN <br /> Facility ID/CERS ID FA0023294 10657183 <br /> Facility Name TIWANA& SONS INC DBA SUBWAY#65214 <br /> Location 2828 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Phone 209-298-6629 x <br /> Mailing Address 5500 Quashnick Rd <br /> Stockton, CA 95212 <br /> Care of TIWANA& SONS INC <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TIWANA, AMRITPAL PAYMENT <br /> Title RECEIVED <br /> Day Phone 209-415-3985 <br /> Night Phone NOV 13 <br /> 2020 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION BANJOAQUINCOUNTY <br /> Account ID AR0042881 ENVIRONMENTAL New Account ID: <br /> Mail Invoices to Account HEALTH DEPARTMENT Mail Invoices to: Owner / Facility / Account <br /> Account Name Vin Tiwana (Circe One) <br /> Email invoice to(up to2 e_mails)_tiwanasubs@gmail.com; tiwanapayrollrecordsl <br /> Email permit to(up to 2 er ls) tiwanasubs@gmail.com; tiwanapayrollrecordsl <br /> Account Balance as of 11/13/2020: $177.00 <br /> (Circle One) <br /> Transfer to Activelinactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PRO540754 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PRO540787 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or r agent of same,acknowledge that all site,andror project specific,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 the laha s will be performed in accordance with all applicable Ordinance Codes andror Standards and State and/or - <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date t I /1-Is / Z U Z 0 <br /> Program Records to be TRANSFERED: = Amount Paid Date <br /> Water System to be�/77`��R��pq,�N`S{p ERED: Amount Paid Date / Z <br /> Payment Type`` LS"F�/� Check Number Receive ? <br /> EHD Staff: Date��/ _/ Account out Date <br /> COMMENTS: Invoice <br /> �c�bl� 1 6 <br />