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Date run 12/10/2014 10:38:46/ SAN JC UIN COUNTY ENVIRONMENTAL HEA �i DEPARTMENT Report#5021 <br /> Run by V1 <br /> Facility Information as of 12/10/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0022455 <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 OW0019880 New Owner ID <br /> Owner Name AMERICAN MEDICAL RESPONSE <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-948-5136 <br /> Mailing Address 400 FRESNO AVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022455 10414963 <br /> Facility Name American Medical Response <br /> Location 455 W Beverly PI <br /> Tracy, CA 95376 <br /> Phone 209-948-5136 x <br /> Mailing Address 400 FRESNO AVE <br /> STOCKTON, CA 95203 <br /> Care of AMERICAN MEDICAL RESPONSE <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041098 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name American Medical Response (Circle One) <br /> Account Balance as of 12/10/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activernactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? ata <br /> 1921 -HMBP-Regular-Primary Location PRO539267 EE0009817-ROBERT LOPEZ Active Y N A DD <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity willbebilledtothepanyidentibedasthe OWNERonthisform. Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andfor <br /> Federal Lewis <br /> APPLICANTS 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 Racei y <br /> REHS: Date_VL/—L-0L/ Account out: Date B l <br /> COMMENTS: <br /> j o, 1.a 2 2013 1 "rL-,, <br />