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Date run 9/26/2014 11:48:14AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 9/26/2014 <br /> Record Selection Criteria: Facility ID FA0021433 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID : <br /> Owner ID OW0017406 New Owner ID <br /> Owner Name PATEL, PRANJAL KUMAR (MD) <br /> Owner DBA <br /> Owner Address 1530 BESSIE AVE 105 <br /> TRACY, CA 95376 <br /> Home Phone 209-836-3967 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1530 BESSIE AVE #105 <br /> TRACY, CA 95376 <br /> Care of GUTIERREZ, ROSEMARY <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0021133 <br /> Facility Name PATEL, PRANJAL KUMAR (MD) <br /> Location 1530 BESSIE AVE# 105 <br /> TRACY, CA 95376 <br /> Phone 209-836-3967 <br /> Mailing Address 1530 BESSIE AVE#105 �—�'1Qy� a2te /�• <br /> z - <br /> TRACY, CA 95376 <br /> Care of ROSEMARY GUTIERREZ <br /> Location Code 03 -TRACY Alt Phone <br /> DOS District 005 - ELLIOTT, BOB Fax <br /> APN 23354005 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ROSEMARY GUTIERREZ <br /> Title CONTACT PERSON/MEDICAL ASSISTANT <br /> Day Phone 209-836-3967 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0038114 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name PATEL, PRANJAL KUMAR (MD) (Cirdeone) <br /> Account Balance as of 9/2612014: $0.00 <br /> (Circle One) <br /> Transferto Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MEd WASTE LIMITED HAULER PR0536798 EE0003973-ROBERT MCCLELLON Active Y N A (DID <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD 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 andlur standards and State andlor <br /> FederaiLaws, <br /> APPLICANT'S SIGNATURE: Date ! I <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: Amount Paid Date ! / <br /> Payment Type Check Number R c by <br /> RENS: �/� C'kQ1� Date L. 1�� Account out: Date q ZIA_l14 <br /> COMMENTS: <br />