Laserfiche WebLink
Date run — 3/512b14 3:17:10PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/5/2014 <br /> Record Selection Criteria: Facility➢D FA0021847 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0017988 New Owner ID <br /> Owner Name ADVANCED HOSPICE INC <br /> Owner DBA ADVANCED HOSPICE INC <br /> Owner Address 4370 AUBURN BLVD <br /> SACRAMENTO, CA 95841 <br /> Home Phone 916-678-5807 <br /> Work/Business Phone Not Specified <br /> Mailing Address 4370 AUBURN BLVD <br /> SACRAMENTO, CA 95841 <br /> Care of DENA JIMENA <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0021847 <br /> Facility Name ADVANCED HOSPICE INC <br /> Location 4370 AUBURN BLVD (A VA I MfLll <br /> SAC RAM E NTO, CA 95841 <br /> Phone 916-678-5807 <br /> Mailing Address 4370 AUBURN BLVD <br /> SACRAMENTO, CA 95841 <br /> Care of DENA JIMENA <br /> Location Code 98 -OUT OF COUNTY Alt Phone <br /> BOS District 000 - UNKNOWN OR OUT OF COUNTY Fax <br /> APN Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DENA JIMENA <br /> Title <br /> Day Phone 916-678-5807 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039786 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name ADVANCED HOSPICE INC (Circle One) <br /> Account Balance as of 31512014: $77.00 <br /> (Circle One) <br /> Transferto AefiveAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PRO537873 EE0003973-ROBERT MCCLELLON Active Y N A I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with t is f illty <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 5 ndlor <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 T e Check Number Received b <br /> RENS: Date l r 1 Account out: Date 17a/ 5 l <br /> COMMENTS: <br />