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Date run 7/16/2012 4:03:35PN SAN J016COUNTY ENVIRONMENTALHE PARTMENT Report 05021 <br /> Run by Pagel <br /> Facility Information as of 7/16/2012 <br /> Record Selection Criteria: Facility ID FA0018251 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> JUL 18 2012OW IP CHANGE(date) <br /> �WNERINFORMATION SSN/Fed Tax I —Ll L-0'2-L <br /> / Owner ID O 003x12 NVIRONMENTAL New Ow er ID (j) 0175 V77 <br /> O <br /> ---� Owner NameT A �IEALTH DEPARTMENT LA VA�A er mG n 1, <br /> Owner DBA SUB AY S;1 .. ,:,� Sc<vl .� z P <br /> Owner Address 5500 UA NICK RD i &L 2_L 1 :nolur Y2nSt tAeJl <br /> STOIC N, CA 95212 1 S-1 >�. uv Cl2 <br /> Home Phone 209-93 - 631 Lv`(- 32 -'i - H L)(Yk <br /> Work/Business Phone 209-4 2-2 80 2 J {— k —LZ 2- > C A;by R <br /> Mailing Address 550 QUAS NICK RD -i c,S 2 , kc1Ut f'G, Ley, <br /> ST CKTON, A 95212 f i ccKt C ZI <br /> Care of T ANA, PAUL S' `'1 '; tY v nC:_YI . <br /> /FACILITY FILE INFORMATI N <br /> l Facility ID FA0018251 <br /> Facility Name SUBWAY SANDWICHES&SALAD <br /> Location 18754 E HWY 26 <br /> LINDEN, CA 95236 Jam- 3 9 <br /> Phone 2G9482-2680-xCELL 20-I ;6c f w <br /> Mailing Address _6596-ftASHN1eK RD 6_52- G�C <br /> SFbeK9c6N,-0A 95212CA G 61 2- <br /> Care of- -PAIjL <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOIS District 004-VOGEL, KEN Fax <br /> APN 10517048 EMsil: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> ContactNameTIWANA, PAUL <br /> Title <br /> Day Phone 209482-2580 Cell ? arc L3 Si l; <br /> Night Phone 209-931-5631 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032123 New An 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 7/16/2012: $0.00 <br /> (Circle One) <br /> Transfer to ActiWInactve <br /> PrograMElemenl and Description Record ID Employee lD and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PRO526939 EE0006213-VIDAL PEDRAZA Active Y/ N A_1D <br /> 1921 -HMBP-Regular-Primary Location PRO536820 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHIPR0536844 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project spec,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the Perry Identified as the OWNER orr,lhis form I also cerlM that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards and State ander <br /> Federal Laws. <br /> I\ rl <br /> APPLICANTS SIGNATURE: T Date / <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water SysterrAO be TRANSFERED: Amount Pal;-16-3-w._ Date 1If i e <br /> Paymt yne 1p _Check Number 0 Q Received b <br /> REHS: ' 1l / Date_/ /_ Account out: Date 7 /� 7 � <br /> comm6h. f <br /> P4Wlul VA � tom. -7116�f L.� 1 13 f JUL`r <br /> / gAN JO vi NDEtpNAENAEN <br /> HF.EANI-VTt''( P�� <br />