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Dille ran 8/26/2014 3:4050PA SAN JUIN COUNTY ENVIRONMENTAL HEA4P DEPARTMENT Report*6021 <br /> Ren p) 1� Pagel <br /> Facility Information as of 8/26/2014 <br /> Record Selection Criteria: Facility ID FA0018251 <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/Fed Tax ID <br /> Owner ID OW0017589 New Owner ID <br /> Owner Name SIDHU, HERMAN S <br /> Owner DBA SUBWAY SANDWICHES & SALAD <br /> Owner Address 4652 TUDOR ROSE GLEN <br /> STOCKTON, CA 95212-9255 <br /> Home Phone 209-323-5863 <br /> Wolk/Business Phone 209-887-2220 <br /> Mailing Address 4652 TUDOR ROSE GLEN <br /> STOCKTON, CA 95212 <br /> Care of SIDHU, HERMAN <br /> FACILITY FILE INFORMATION <br /> Facility ID I 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 4652 TUDOR ROSE GLEN <br /> STOCKTON, CA 95212 <br /> Care of SIDHU, HERMAN <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 10517048 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SIDHU, HERMAN <br /> Title <br /> Day Phone 209-366-3691 <br /> Night Phone 209-887-2220 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032123 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SUBWAY SANDWICHES&SALAD (Circle One) <br /> Account Balance as of 8/26/2014: $0.00 <br /> (Circle One) <br /> Transferlo ActivellnscNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PR0526939 EE0008999-LEYNA HUYNH Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0536820 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,anNor pri specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this farm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State anclor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date ! ! Account out: Date / / <br /> COMMENTS: <br />