Laserfiche WebLink
Date run 5/20/2016 4:22:09PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 5/20/2016 <br />Record Selection Criteria: Facility ID FA0023481 <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 OW0021728 New Owner ID : <br />Owner Name Jennifer Miller 15VbJL4 ti <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 941-359-7930 <br />Mailing Address 2650 Tallevast Road <br />Sarasota, FL 34243 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0023481 10661935 <br />Facility Name <br />Hospital LS <br />Location <br />1772 E Scotts Ave <br />Stockton, CA 95205 <br />Phone <br />941-962-9359 x <br />Mailing Address <br />2650 Tallevast Road <br />Sarasota, FL 34243 <br />Care of <br />Evoqua Water Technologies LLC <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0043282 <br />Mail Invoices to Account <br />Account Name Michael Smee <br />Account Balance as of 5/20/2016: $0.00 <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/]nactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0541019 EE0000006 - HAZA SAEED Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD 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 andlor <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 />EHD Staff: k NO Date Account out: Date �5 <br />COMMENTS: <br />Invoice #: <br />N(�-J U` 1i 6� tlo� R--Pr.,� 5 <br />