Laserfiche WebLink
Date run 4/27/2015 2:44:26Pk SAN JOIN COUNTY ENVIRONMENTAL HEA&DEPARTMENT <br /> Report 25021 <br /> Run by Pagel <br /> Facility Information as of 4/27/2015 <br /> Record Selection Catena: Facility ID FA0022161 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) A— L—A— <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner lD OW0018242 New Owner ID <br /> Owner Name Western Dental Services, Inc. <br /> Owner DBA <br /> Owner Address 530 S MAIN ST <br /> ORANGE, CA 92868 <br /> Home Phone Not Specified <br /> Work/Business Phone 714-480-3000 <br /> Mailing Address 530 S. Main Street <br /> Orange, CA 92868 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022161 10449784 <br /> Facility Name Western Dental <br /> Location 1407 W March Ln <br /> Stockton, CA 95207 <br /> Phone 209-473-4000 x <br /> Mailing Address 530 S. Main Street <br /> Orange, CA 92868 <br /> Care of WESTERN DENTAL SERVICES, INC. <br /> Location Code ^, Alt Phone <br /> BOS District Fax <br /> APN �� _ ,EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION �\ <br /> Contact Name of <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ,�t,rw•y w <br /> Account ID AR0040381 \�� \ New Account ID: <br /> Mail Invoices to Account y'p� �n�� Mail Invoices to: Owner / Facility / Account <br /> Account Name Western Dental '1Yy1 \(V"l \ (Circle One) <br /> Account Balance as of 4/27/2015: $0.00 \ \ / �(� <br /> (clrGe one) <br /> Transfer to Acgve/Inactve <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? ( Delete <br /> 1921 -HMBP-Regular-Primary Location PRO539214 EE0009817-ROBERT LOPEZ Active Y N A Q D <br /> 2220-SM HW GEN<5 TONS/YR PRO538344 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 certBy that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State encvor <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 Received by <br /> REHS: Date Account out: Date <br /> COMMENTS: <br /> �m s e R=-- c� <br />