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Data run 10/18/2017 4:63:17P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reporta5021 <br /> Run by - Pagel <br /> Facility Information as of 10/18/2017 <br /> Record Selection Cnleda: Facility 10 FA0023824 <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: 2 SSN/Fed Tax ID : <br /> Owner ID OW0015675 New Owner ID <br /> Owner Name Barry Stirm <br /> Owner DBA STIRM FAMILY INC <br /> Owner Address 12352 E STATE ROUTE 12 <br /> LOCKEFORD, CA 95237 <br /> Home Phone 209-200-2323 <br /> Work/Business Phone 209-200-2323 <br /> Mailing Address 12352 E State rt 12 //)3 % U1&e_ D 19- <br /> Lockeford, CA 95237 1 �J.5eZ`Ff:) <br /> Care of STIRM, BARRY C <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0023824 10724521 <br /> Facility Name SUBWAY#67296 <br /> Location 1600 W GATE DR <br /> LODI, CA 95242 <br /> Phone 209-200-2323 x <br /> Mailing Address 1601 S. Lower Sacramento Rd. <br /> Lodi, CA 95242 <br /> Care of Stirm Family Inc. 67296 <br /> Location Code 02 - LODI Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name STIRM, BARRY C <br /> Title <br /> Day Phone 209-452-2499 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0044133 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Stirm Family Inc (Circle One) <br /> Account Balance as of 10/18/2017: $172.00 <br /> (Circle One) <br /> Tmnsferto Active/lnaci <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1617-RETAIL MARKET>1000 SQ FT W/FOOD PREP PR0541554 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PR0541978 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PR0541980 EE0001084-STEPHANIE RAMIREZ Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. 1,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER on this form. I also certifythat all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State andfor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: �� �4L1/hl�.�/ 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 by <br /> // <br /> EHD Staff: Date / / Account out: Date 16 / /7 <br /> COMMENTS: <br /> Invoice#: <br />