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Date run 9/5/2014 1:51:44PM SAN JO IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Repent#5021 <br /> Run by Pagel <br /> Facility Information as of 9/5/2014 <br /> Record Selection Cnana: Facility lD FA0018251 ;u <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: 1 SSN Tax ID . Z-)' '�O(o 2S � <br /> Owner ID OW0017589 New Owner ID <br /> Owner Name &I_B�AN!-SOwner DBA DBA SUBWAY SANDWICHES & SALAD <br /> Owner Address 4652-f{fBeR-ROSE-Ek Y09 4iLAPO&Y couPT <br /> SR9GKFAN EA952-�5 ( vt (NPoPf C A IS33a <br /> Home Phone 2- HISS 7 <br /> Work/Business Phone 209-887-2220 <br /> Mailing Address 4652-TJQGf-R4DS€-GLEN $QC Kku't- /Ui=Y COUNT <br /> STgG{FFeN�95M LU o o(S33o <br /> Care of_SjDb�- E-RMAIq— UI�Vf � 6'csp" <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018251 10186829 <br /> Facility Name SUBWAY SANDWICHES & SALAD <br /> Location 18754 E HWY 26 <br /> LINDEN, CA 95236 <br /> Phone 209-366-3691 <br /> Mailing Address X52--Tf})OR-RO$E-Gt€-N-- bk r-tLARt,_eY coUR7 <br /> STgeKTON, CA-95212 VCfFi cA IIS3 30 <br /> Care of &IDH"EF T0AN-- <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 10517048 EMail: Ca9EPC5iR:,S If gAHd6,C6A4 <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION PAYMENT y <br /> Contact Name-9[DHU-HERfV f �ECEl�En I Ut Y( Ga �- <br /> Title <br /> Day Phone-,209-3663694 SEP 209QK7-2Z2o <br /> Night Phone-288=$87=2220- TV 20c7- 232 - <br /> ACCOUNTS RECEIVABLE FILE INFORMATION JOAOUIN COON. <br /> SA ENVIROMENTIM <br /> LTH DEPARTMENT New <br /> Account ID AR0032123 H� <br /> Mail Invoices to Facility Mail Invoices to: wne Facility / Account <br /> Account Name SUBWAY SANDWICHES &SALAD (ClrcleOne) <br /> Account Balance as of 9/5/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Desorption Record ID Employee ID and Name Status New Owner! Delete <br /> ESTAURANT/BAR 21-50 SEATS PR0526939 EE0008999-LEYNA HUYNH Active Y N A I D <br /> f921 -HMBP-Regular-Primary Location PRO536820 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0536844 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,PH&EHD houdy charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also ofrtify that all operations will be performed In accordance with all applicable Ordinance Codes and/or Standards and State antler <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Y- `li(�S `� _ Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRA"C'JSFERED: Amount Pai Date / <br /> Payment Type t/ Check Number DqlZ Recei ed b <br /> REHS: /1/)- Date Account out: Date <br /> COMMENTS: <br />