Laserfiche WebLink
Date mn 2/12/2002 2:41:12PR SAN JO -IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/12/2002 <br /> 01 <br /> Record Selection Criteria: Facility ID FA0007676 <br /> Make changesicorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <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 �e�S� IfYlCFi�II�i� ?E 2?33 baLau54 <br /> Locaticd 1617 N CALIFORNIA ST 1A -�}��-r S�Ivw_*^-t�'e�'}tv�2rc1-'i5 r^e� (orgty' <br /> STOCKTON, CA 95204 <br /> Phone 209-948-6063 <br /> Mailing Address 2320 N CALIFORNIA ST F3o-f- `�I Qy oA cif ZZZn / &4,pt— <br /> STOCKTON, CA 95204 -�-t�n r e a=rV.n r l Ff u)n cn ii a *n✓ <br /> Care of ORLIN KOEHMSTEDT f <br /> Location Code 01 -STOCKTON h APN. <br /> BOS District 002 - MARENCO, DARIO Hyl 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 (Circle one) <br /> Account Balance as of 2/12/2002: $129.50 <br /> (Circle One) <br /> Transfer to ActNe/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2213-HAZ WASTE CE FAC STATE SERVICE FEE PRO506927 EE0000418-MICHAEL KITH Inactive Y N A D <br /> 2233-HAZARDOUS WASTE CESOT FACILITY PRO506926 EE0000418-MICHAEL KITH Active Y N A I D <br /> 399-UNIFIED PROGRAM FAC STATE SERVICE FPRO506928 EE0000418-MICHAEL KITH Active Y N A I D <br /> V q <br /> BILL NG and COMPLIANCE ACKNOWLEDGEMENT: I,the undersignedPF--54b24 <br /> owner o�p§rator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or acfivity 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 Ordinace Codes and/or Standards and <br /> State ardor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: `� Date <br /> COMMENTS: <br /> ZN� Q05¢(o 212-71 02- <br /> \\Phs-ehsgf-nt\apps\Envisions\Reports\5021.rpt <br />