Laserfiche WebLink
Date run 1/10/2014 3:49:28PE SAN JON l COUNTY ENVIRONMENTAL HEAISODEPARTMENT Report#5021 <br /> Run by Papel <br /> Facility Information as of 1/10/2014 <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 10458379 <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 NewAccount 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 1/10/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activenracive <br /> Progra"Elemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> �9 HMBP-Reqular-Primary Location PR0538332 (.;b PC•%" Active Y N A I D <br /> SM HW GEN<5 TONSNR 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,andor protect spark,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 andfor Standards and State andor <br /> Federal Laws <br /> APPLICANT'S 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 Type Check Number Received by <br /> REHS: �• N(7l Date I/ t / t Account out: (/6 Date I I I '� /1 4. <br /> COMMENTS: <br /> o oV') Pe- (tet 22'vo (/l4 <br /> gdct.;&11 ' <br />