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Date run 7/30/2012 2:54:34PR SAN JC&IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/30/20 2 <br /> Record Selection Criteria: Facility ID FA0020078 <br /> Make changes/corrections in RED ink. 3b <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008985 Case Number: 1-1691 3 New Owner ID <br /> Owner Name GULLY, VINCE <br /> Owner DBA ff <br /> Owner Address PO BOX 5308 ST <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-4136-9641 Z L-( $2— L4,53 <br /> Mailing Address PO BOX 5308 <br /> STOCKTON, CA 952050308 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0020078 <br /> Facility Name rndc EORKI IGT (� W e,Q erpJ r NC• <br /> Location 2354 E MINER AVE <br /> STOCKTON, CA 95205 <br /> Phone 209-466-3041 <br /> Mailing Address PO BOX 5308 <br /> STOCKTON, CA 95205 <br /> Care of GULLY, VINCE <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 15324024 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name VINCE GULLY <br /> Title <br /> Day Phone 209-466-3041 <br /> Night Phone 14 2- <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0035811 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name GMS FORKLIFT (Circle One) <br /> Account Balance as of 7/30/2012: $0.00 <br /> (Circle One) <br /> Transfer to Active9nactve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PRO531169 EE0009488-JEFFREY WONG Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0534027 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor 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 anclor Standards and State andfor <br /> Federal Laws. <br /> APPLICANTS 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 T e Check Number Received by <br /> REHS: .. Vr,9'�, 1 MDate�jo C/ llAccount out: Date <br /> COMMENT N U .! <br />