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Date run : 512100 11:31:27AM SAA' AQUIN COUNTY PUBLIC HEALTH SEF :ES Report #: 0002 <br /> Run by SDRISCOL Facility Informatkmo ion as of 512100 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0007968 <br /> Record ID <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0006586 New owner ID <br /> Owner Name: ARS HEARTWATCH <br /> Owner DBA: ARS HEARTWATCH <br /> Owner Address: 518 BRECK CT <br /> BENECIA, CA 94510- <br /> Home Phone: 800-418-7108 <br /> WorklBussness Phone: Not Specified <br /> Mailing Address: 518 BRECK CT <br /> BENECIA, CA 94510- <br /> Care of: ARS HEARTWATCH <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0007968 <br /> Facility Name: ARS HEARTWATCH <br /> Location: 518 BRECK CT <br /> BENECIA, CA 94510 <br /> Phone: 800-418-7108 <br /> Mailing Address: 518 BRECK CT <br /> BENECIA, CA 94510- <br /> Care of: ARS HEARTWATCH <br /> Location Code: 98- OUT OF COUNTY APN; <br /> BOS District- SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0014787 New Account ID:: <br /> Mail Invoices to: Facility Mail Invoices to: Owner/ Facility /Account <br /> Account Name: ARS ATCJH Circle One) <br /> Account Balance as of 512100: 67.00 0j <br /> �(J l• (Circle <br /> UST(s) Transfer to Active acty <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Dele e <br /> 4557-MED WASTE LIMITED HAULER PRO508162 EE0000988-FOLEY Active Y N I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent?I-same,acknowledge that all site,and/orproject <br /> specific PHS/EHD hourly charges associated with this facility or activity will be billed to theparty identified as the BILLING PARTY on thisform. I <br /> also ceyYify that all operations will be performed in accordance with all applicable Ordinate Codes an or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: *$150.00 Amount Paid Date 1 / <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date 1 ! Account out: Date / 1 <br /> 1.0.0.89.00 <br />