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Date run 9/26/2014 11:43:02AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/26/2014 <br /> Record Selection Criteria: Facility ID FA0019862 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: t SSN 1 Fed Tax ID <br /> Owner ID OW0016292 New Owner ID <br /> Owner Name US HEALTHWORKS <br /> Owner DBA US HEALTHWORKS <br /> Owner Address 3663 E ARCH RD 400 <br /> STOCKTON, CA 95215 <br /> Home Phone 209-943-2202 <br /> WorklBusiness Phone Not Specified <br /> Mailing Address 3663 E ARCH RD STE 400 <br /> STOCKTON, CA 95215 <br /> Care of CHEVALIER, MARIE <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0019862 <br /> Facility Name US HEALTHWORKS <br /> Location 3663 E ARCH RD STE 400 <br /> STOCKTON, CA 95215 <br /> Phone 209-943-2202 <br /> Mailing Address 25124 SPRINGFIELD CT STE.200 F--nou– *v•e. *S57 per P— �• <br /> VALENCIA, CA 91355 <br /> Care of TAX DEPARTMENT <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 17926018 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MARIE CHEVALIER <br /> Title <br /> Day Phone 209-943-2202 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0035382 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name US HEALTHWORKS (Circle One) <br /> Account Balance as of 9/26/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> PrograrnlEtement and Description Record ID Employee ID and Name Status New OwneP. Delete <br /> 4557-MED WASTE LIMITED HAULER PRO530493 EE0003973-ROBERT MCCLELLON Active Y N A (I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: t,the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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 anNor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> RENS: 12 16!S Date. /6 17-1 f Account out: -.-- Date '�y Z� I(1 <br /> COMMENTS: <br />