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Date run 12/4/2013 9:30:52AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/4/2013 <br /> Record,Selection Criteria: Facility ID FA0019512 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0015990 New Owner ID <br /> Owner Name SYNERGY HEALTH COMPANIES INC <br /> Owner DBA INTERIM HEALTHCARE <br /> Owner Address 111n Tt u t v on cTE '+ IS 2-1 M. CariDen-Vev . , e. © k <br /> flAllflCOTG &A _95358 P°IodeSt-o � CA 9S 351-, 12 1 <br /> Home Phone 209-577-4625 <br /> Work/Business Phone Not Specified <br /> Mailing Address saime 0..S 0. Ogle. <br /> Care of MURPHY, RON <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019512 <br /> Facility Name INTERIM HEALTHCARE <br /> Location e Cx.S 0.bo�re <br /> Phone 209-577-4625 x200 <br /> Mailing Address 449 Tt tt t v on ST`C CJa�e p�S p��•�� <br /> Care of RON MURPHY <br /> Location Code 98 -OUT OF COUNTY Alt Phone <br /> BOS District 000 - UNKNOWN OR OUT OF COUNTY Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RON MURPHY <br /> Title <br /> Day Phone 209-577-4625 x200 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034710 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name INTERIM HEALTHCARE (Circle One) <br /> Account Balance as of 12/4/2013: $77.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PR0529375 EE0003973-ROBERT MCCLELLON Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with this facility <br /> or activity 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 Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: 116 Date a / D �2' <br /> COMMENTS: <br />