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Date run 2/15/2006 9:08:53AR SAN JOA'-'IN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Report#5021 <br /> Pagel <br /> Run by lft'' Facility Information as of 2115/2006 <br /> Record selection Criteria: Fadliy ID FA0007676 <br /> Make changeslcorrections In RED Ink or pencil. <br /> INFORMATION CHANGE(date) -7,47AOto <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0006340 New Owner ID <br /> Owner Name DELTA RADIOLOGY MEDICAL GRP <br /> Owner DBA <br /> Owner Address 1617 N CALIFORNIA ST 1 A <br /> STOCKTON, CA 95204 <br /> Home Phone 209-948-6063 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2320 N CALIFORNIA ST <br /> STOCKTON, CA 95204 <br /> Care of KOEHMSTEDT, ORLIN <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007676 <br /> Facility Name DELTA RADIOLOGY MEDICAL GRP lArfA <br /> Location 1617 N CALIFORNIA ST 1A �— <br /> STOCKTON, CA 95204 <br /> Phone 209-948-6063 <br /> Mailing Address 2320 N CALIFORNIA ST <br /> STOCKTON, CA 95204 <br /> Care of ORLIN KOEHMSTEDT <br /> Location Code 01 -STOCKTON APN:12715050 <br /> BOS District 002 -MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0013264 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DELTA RADIOLOGY MEDICAL GRP (Cade Or <br /> Account Balance as of 2/15/2006: $74.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> PrograndElement and Description Record ID Employee ID and Name Status New Ormer? Delete <br /> 2213-HAZ WASTE CE FAC STATE SURCHARGE FPR0506927 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2222-SILVER WASTE ONLY-<5 TONSNR PRO518219 EE0008373-JOMN-JAeKS9N Active Y N A _C D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO518850 EE0000418-MICHAEL KITH Inactive Y N A 1 D <br /> 2233-HAZARDOUS WASTE CESOT FACILITY PR05D6926 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARiPRO5D6928 EE0000418-MICHAEL KITH Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date / ! <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date I / <br /> COMMENTS: <br /> t�RS e� <br /> PI� �S�\\ See a 0. rQ.-�CLI ysC"'"' Dy <br /> \\phs�hsgl-nt\apps\envisions\reports\5021.rpt <br />