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Date <br /> Run b n 7/15/2015 8:4106AR SAN J(.�UIN COUNTY ENVIRONMENTAL HEA wilt DEPARTMENT p #5ozl <br /> Y Report <br /> Facility Information as of 7/15/2015 Pagel <br /> Record Selection Critera: Facility ID FA00134$9 <br /> Make changeslcorrections in RED ink. d <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 OWNERSHIP CHANGE(date) <br /> SSN 1 Fed Tax ID <br /> Owner ID OW0010623 New Owner 1D <br /> Owner Name GVR, INC <br /> Owner DBA GVR, INC <br /> OwnerAddress 3400 GRIMSHAW WAY <br /> ELK GROVE CA 95758 <br /> 44o 1-1 <br /> Home Phone`2 <br /> Work/Business Phone 948x9557 <br /> Mailing Address 2256 N WILSON WAY <br /> os�.' <br /> STOCKTON, CA 95205 ., <br /> Care of SAIENNI, JOE K <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0013489 <br /> Facility Name GVR, INC <br /> Location 2256 N WILSON WAY fv, OL r Q <br /> STOCKTON, CA 95205 <br /> Phone 209_948-9557 f--::D l 3 14 <br /> Mailing <br /> - <br /> Mailing Address 2256 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of SAIENNI, JOE <br /> Location Code 99_ UNINCORPORATED A Alt Phone <br /> BOS District Fax <br /> APN 11711038 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION ' <br /> Contact Name SAIENNI, JOE C� <br /> Title <br /> Day Phone 209_529-5350 <br /> Ar— <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022569New Account ID: <br /> oc <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility I Account <br /> Account Name GVR, INC ���o re (Circle One) <br /> Account Balance as of 7/15/2015: $0.00 (/►�W <br /> ©b La tu�lJ\( r (Circle One) <br /> �l �'�/�' Transfer to ActiveAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owl Delete <br /> 1644-VENDING MACHINES PR0517527 EE0009488-JEFFREY WONG Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and+or project specific,PHSIEHD 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 andlor Standards and State an Nor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date 1/5-1 <br /> COMMENTS: _ <br /> Invoice#: <br /> 4 <br />