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Date run 2/18/2014 8:19:19AN SAN JUIN COUNTY ENVIRONMENTAL HEAV DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/18/2014 <br /> Record Selection Criteria: Facility ID FA0002361 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) D <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003612 New Owner ID <br /> Owner Name TIWANA, AMRITPAL S <br /> Owner DBA SUBWAY <br /> Owner Address 5500 QUASHNICK RD <br /> STOCKTON, CA 95212 <br /> Home Phone 209-931-5631 <br /> Work/Business Phone 209-482-2580 <br /> Mailing Address 5500 QUASHNICK RD <br /> STOCKTON, CA 95212 <br /> Care of TIWANA, PAUL <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0002361 10,419,718 <br /> Facility Name Subway#15879 <br /> Location 4410 E Waterloo Rd Highway 88 <br /> Stockton, CA 95215 <br /> Phone 209-482-2580 x <br /> Mailing Address 5500 QUASHNICK RD <br /> STOCKTON, CA 95212 <br /> Care of TIWANA& SONS INC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 002-RUHSTALLER, LARRY Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name AMRITPAL TIWANA <br /> Title <br /> Day Phone 209-931-5631 <br /> Night Phone 209-482-2580 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002374 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Subway#15879 (Circle One) <br /> Account Balance as of 2/18/2014: $0.00 <br /> (Circle One) <br /> Transfer to AcWe nactve <br /> Program/Element and Description Record 10 Employee ID and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PRO161740 EE0008999-LEYNA HUYNH Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0538674 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 3116-STORMWATER INSPECTION-FOOD PR0523051 EE0006213-VIDAL PEDRAZA 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,PHSfEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as We OWNER on this fomt I also certify Nat all operations will be performed in accordance with all applicable Ordinance Codes endor Standards and Slate andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <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 Receiv�tt'IN <br /> REHS: �r� 1:q Lu Date�,/ J� Account out: (�'� Date o7 1 Z <br /> COMMENTS: <br /> ( � Z <br />