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Date run 2/6/2007 8:30:12AM SAN JO UIN COUNTY ENVIRONMENTAL HEA1 T DEPARTMENT Report%5021 <br /> Run by L. `✓ Pagel <br /> Facility Information as of 2/6/2007 <br /> Record Selection Criteria: Facility ID FA0012382 <br /> ru Make changes/corrections in RED ink or pent / <br /> INFORMATION CHANGE(date) L <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009028 Case Number: H09183 New Owner ID <br /> Owner Name AMERICAN MEDICAL RESPONSE <br /> Owner DBA AMERICAN MEDICAL RESPONSE-LODI <br /> Owner Address 215 CAMPUS WAY <br /> MODESTO, CA 95350 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-948-5136 <br /> Mailing Address 7575 SOUTHFRONTRD <br /> LIVERMORE, CA 94551 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012382 x, <br /> Facility Name AMERICAN MEDICAL RESPONSE <br /> Location 247 CHARTER WAY Y S� <br /> STOCKTON, CA 95206 <br /> Phone 209-557-9778 <br /> Mailing Address 215 CAMPUS WAY <br /> MODESTO, CA 95350 <br /> Care of <br /> Location Code 01 -STOCKTON APN:14708418 <br /> BOS District 001 -GUTIERREZ, STEVE SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020236 New Account ID <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AMERICAt4l MEDICAL RESPONSE (Circle One) <br /> Account Balance as of 2/6/2007: $200 <br /> (Circe One) <br /> Transfer to Active/InaWa <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneO Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO515924 EE0000753-WILLIE NG Active Y N A Q7 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO515925 EE0009999-SITE UNASSIGNED Inactive y,LC Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO520814 EE0000000-HAZ MAT SJC OES Inactive k-\' Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPR0515926 EE0009999-SITE UNASSIGNED Inactive J V" pv,Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0523916 EE0004636-GARRETT BACKUS Active ,w. Y N A , I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Me 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 Me party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordineee Codes and/or Standards and <br /> State and/or Federal Laws. U'////1 DD <br /> APPLICANTS SIGNATURE��y /L�,_/ ,: Date '�A / G 1� <br /> Program Records to be TRANSFERED: // __ $20.00= Amount Paid Date_/_/_ <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date I / <br /> Payment Type Check Number Received by 13 Z !-('(D 7 <br /> RENS: fro 0 3 z/ Date .V-/ / 0Z Account out: Date ./_t2_/_j <br /> COMMENTS: <br /> /�J D t oAn�R�rr <br /> �cSS <br /> FEB <br /> BJJJ-- 61111 7007 <br /> ENVIRONMENT HEALTH <br /> \\phs-ehsgl-nt\apps\enviSion s\reports\5021.rpt PERMIT/SERVICES <br />