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Date run 10/3/2006 1:02:57Ph SAN JOr TJIN COUNTY ENVIRONMENTAL HEAL t Report#5021 DEPARTMENT Pagel <br /> Run by 5290 Facility Information as of 10/3/20�lvrl <br /> Record Selection Cntena: Facility ID FA0013489 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION FILE <br /> Owner ID OW0010623 New Owner ID <br /> Owner Name c" "a^R I ' /AcACTf6N 1NG 111142 <br /> � ,�'^/ <br /> Owner DBA �� �'��C <br /> Owner Address 3400 GRIMSHAW WAY <br /> ELK GROVE, CA 95758 <br /> Home Phone 209-948-9557 <br /> Work/Business Phone 209-948-9557 <br /> Mailing Address 2256 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of SAIENNI, JOE K <br /> FACILITY FILE INFORMATION - <br /> Facility ID FA0013489 <br /> Facility Name - - <br /> Location 2256 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Phone 209-948-9557 <br /> Mailing Address 2256 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of SAIENNI, JOE APN:11711038 <br /> Location Code 99 - UNINCORPORATED AREA <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022569 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name A-.AGT}ON VE-45 NG (Circle One) <br /> Account Balance as of 10/3/2006: $308.00 <br /> (Circe One) <br /> Transfer to Active/Inaclve <br /> New Owner? Delete <br /> Progmm/Elemenl and Description Record ID Employee ID and Name Status <br /> 1644-VENDING MACHINES PRO517527 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific.PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performetl in accordance with all applicable Ortlinace Codes and/or Standards and <br /> Stale and/or Federal Laws. l <br /> APPLICANTS SIGNATURE: L 1,-_„g Date <br /> Program Records to be TRANSF>� '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Reovd b <br /> REHS: Date / / Account out: 1v Date M/ 7—T-/ u )b <br /> COMMENTS: <br /> \\phsehsgl-nt\apps\envisions\reports\5021.rpt <br />