Laserfiche WebLink
Dae ma. 2/11¢/2014 9:56AOAk SAN J(yiUIN COUNTY ENVIRONMENTAL HEA�/I DEPARTMENT Paget#50 <br /> Repos 21 <br /> Ru,"by 1273 Facility Information as of 2/18/2014 <br /> Record Selection Criteria: Facility ID FA0021322 <br /> Make Changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0017577 New Owner ID <br /> Owner Name Satellite Healthcare <br /> Owner DBA SATELLITE DIALYSIS CLINIC <br /> Owner Address 300 SANTANA ROW 300 <br /> SAN JOSE, CA 95128 <br /> Home Phone 650-404-3600 <br /> Work/Business Phone 560-404-6500 <br /> Mailing Address 300 Santana Row#300 <br /> San Jose, Ca 95128 <br /> care of GRENZ, TERRI <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021322 10,458,379 <br /> Facility Name Satellite Dialysis University Park <br /> Location 590 E Harding Way <br /> Stockton, CA 95204 <br /> Phone 916-437-5800 x <br /> Mailing Address 590 E. March In. <br /> Stockton, Ca 95204 <br /> Care of Satellite Healthcare <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY 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 AR0038650 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Satellite Dialysis University Park (Circle One) <br /> Account Balance as of 2/18/2014: $503.00 <br /> (Circle One) <br /> Transfer to Active/Inach,e <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner1 Delete <br /> 1921 -HMBP-Regular-Primary Location PRO538332 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0538331 EE0009488-JEFFREY WONG Active Y N A I D <br /> 4530-LG QUANITY GENERATOR PR0537144 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor protect specHic,PHSrEHD 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 ancror Standards and State and'or <br /> Federal Laws, <br /> APPLICANT'S 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 Receiv d <br /> REHS: Date / /_ Account out: Date '7' / / <br /> COMMENTS: <br />