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Date ruh : 2,/27/01 9:57:27AM SAP ')AQUIN COUNTY PUBLIC HEALTH SEr CES Report u 0002 <br /> Run by LBROWN Facility Information as of 2/27/01 Page #- 1 <br /> Rewrd Selection Criteria: FacilityID FA0007679 <br /> ReeoW ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID. OW0006342 New Owner ID <br /> Owner Name, K <br /> Owner DBA: DELTA RADIOLOGY MED GRP <br /> Owner Address: 1121 W VINE ST <br /> LODI, CA 95240- 44 n , l <br /> Home Phone: Not Specified <br /> work/Bussness Phone: 209-466-5027 <br /> Mailing Address: 1121 W VINE ST <br /> LODI, CA 95240- <br /> Care of: ORLIN KOEHMSTED <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0007679 �e �+a <br /> Fa '1iry Name: DELTA RADI OGY MED GRP V 0 MC.G� <br /> oeation: 2420 N CALI ORNIA ST 7 �.�a0 N , D ►uti �{.3 . <br /> STOCKTO CA 95204 <br /> P <br /> no: 209-466- 27 S'ID �Yl <br /> Mailing Address. 2420 ALIFORN IA ST <br /> TO ON, CA 95204- <br /> care of: O N KOEHMSTED <br /> Location Code: 1 -ST KION APN: <br /> Bos District 002 -MA CO, DARIO SIC code; <br /> ACCOUNTS RECEIVABLE FILE I ORMATION O'Y�-/ <br /> Accou tID: AR0013267 New Account ID:p �l <br /> Mail Invoices to: Facility Mall Invoices to: Owner/Facility /Account <br /> Account Name: DELTA RADIOLOGY MED GRP (Circle One) <br /> Account Balance as of 2/27/01: $110.00 <br /> (Circle One <br /> UST(s) Transferto Active/Inactv <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2233-HAZARDOUS WASTE CESQT FACILITY PRO506944 EE0000418-KITH Inactive Y N 1 <br /> 2213-HAZ WASTE CE FAC STATE SERVICE FEE PR0506945 EE0000418-KITH Inactive Y N 1 <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F P 06 6 EE0000418-KITH 05 11i7-/0 Active Y N I <br /> 2220-SM HW GEN<5 TONSNR PRO EE0000418-KITH 0Sll,?F,LJ Active Y N I <br /> hLW Il t t!w b tAD 1JL klk) W4, <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned ner,operator or went o�'same,acknawle$ge that aU site,and/orproject <br /> specific,PHSIEHD hourly charges associated with this facility or adhity wiU be billed to theparty rdentrJkd as the BILLI1 GPARIYon thisform II <br /> also cent/y that all operations wrG be performed in accordance with all appUcable Ordinate Codes and/or Standards and State amLor Federal Laws <br /> ✓�u(,� c.��- � o�aao5 <br /> APPLICANTS SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date / / <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date / / Account out: Date <br /> 1.0.0.89.00 <br />