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Date run 9/7/2018 4:14:19PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/7/2018 <br /> Record Selection Criteria: Facility ID FA0018873 <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 OW0021744 New Owner ID <br /> Owner Name FIREHOUSE RJJM <br /> Owner DBA FIREHOUSE SUBS <br /> Owner Address 633 TEESDALE RD <br /> YUBA CITY, CA 95991 <br /> Home Phone 530-300-4423 <br /> Work/Business Phone 209-851-2563 <br /> Mailing Address 633 TEESDALE RD <br /> YUBA CITY, CA 95991 <br /> Care of ESPINOZA, RUBEN <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018873 10743808 <br /> Facility Name FIREHOUSE SUBS <br /> Location 7860 WEST LN STE B-1 <br /> STOCKTON, CA 95210 <br /> Phone 209-851-2563 <br /> Mailing Address 633 TEESDALE RD <br /> YUBA CITY, CA 95991 <br /> Care of ESPINOZA, RUBEN <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 09404008 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ESPINOZA, RUBEN <br /> Title <br /> Day Phone 209-851-2563 <br /> Night Phone 530-300-4423 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION 1� <br /> Account ID AR0033550 �((� f New Account ID: <br /> Mail Invoices to Facility — \ Mail Invoices to: Owner / Facility / Account <br /> Account Name FIR USE SUBS (Circle One) <br /> Account Balance as of 9/7/20 8: $-170.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PR0527841 EE0078788-GEHANE FAHMY Active Y N A B D <br /> 1919-HMBP-0O2 Only Food Facility PR0542147 EE0078788-GEHANE FAHMY Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD 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 that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andror <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 Received b/ <br /> EHD Staff: o �" Date� / 2/� Account out: Date�/ /� <br /> COMMENTS: <br /> Invoice#: <br /> f. �,� �0 A Gc � u GG +C�i/ � 2��/l vt� 7Ke <br />