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Date me 1/23/2006 12:2920PK SAN 3C `UIN COUNTY ENVIRONMENTAL HEA H DEPARTMENT Report#5021 <br /> Run by 5290 1. Pagel <br /> Facility Information as of 1/23/2006 <br /> Record Selection Criteria: Fadlity ID FA0012382 <br /> Make changes/corrections in RED ink or penc . / <br /> INFORMATION CHANGE(date) <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 (CHA <br /> Owner Address `fir 5 �AYI,✓�lA-g <br /> lY10 11L0 tDLR 3 <br /> Home Phone Not Specified <br /> Work/Business Phone 925-454-6072 <br /> Mailing Address 7575 SOUTHFRONT RD <br /> LIVERMORE, CA 94551 } YI 0 701y tp35?� <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012382 <br /> Facility Name AMERICAN MEDICAL RESPONSE <br /> Location 247 CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Phone 209-557-9778 <br /> Mailing Address 7575 SOUTHFRONT RD GJ" <br /> LIVERMORE, CA 94551 _�')1 it( ) !i� / l6rt, 3 S L <br /> Care of <br /> Location Code 01 - STOCKTON APN 147-084-18 <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 AMERICAN MEDICAL RESPONSE (CirdeOna) <br /> Account Balance as of 1/23/2006: $0.00 <br /> cirde One) <br /> Transfer to Acfive/Inadve <br /> Progra utElemers and Desorption Riad ID Ernployee ID and Name Status Nen Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO515924 EE0000753-WILLIE NG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIONPRO515925 EE0009999-SITE UNASSIGNED Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO520814 EEOOO0000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARG)R0515926 EED009999-SITE UNASSIGNED Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523916 EEDD04636-GARRETT BACKUS Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Me undersigned avow,operator or agent of sane,arknovledge that all site.and/or project specific.PHS/EHD houdy charges associated war Mrs <br /> fadlity or edivrty will be billed to the party identified as the OWNER an this form. I also caddy that all operations wil be performed in a=ndaice wdM ell applicable Ordinate Codes and/or Standards and <br /> State aid/or Federal Lars. <br /> APPLICANT'S SIGNATURE: Dale <br /> Program Records to be TRANSFERED: •$20.00= Amount Paid Dale / / <br /> Water System to be TRANSFERED: •$372.00= Amount Paid Date / / <br /> Payment Type Check Number Received <br /> REHS: Date_/ / Account out: /- Date / / 2 '�/ U� <br /> COMMENTS: <br /> \tphsehsgl-nt%appslenvisionsYeportst5021.rpt <br />