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Daterun. ' 2/3/2005 8:58:OlAM SAN JC "TIN COUNTY ENVIRONMENTAL HEAT m''DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 213120eT� <br /> Record Selection Criteria: Facility ID FA0007968 <br /> Make changes/corrections 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 Z4 -B3REGJE-C'T O I <br /> 0-UQ h a=ftArP.et d:±;1 . A. 54 75 1(,SP <br /> Home Phone 925-952-9265 <br /> Work/Business Phone Not Specified <br /> Mailing Address 11477 N1E4N9GAAF304EW-WA-Y <br /> ROUGH AND READY, CA 597-07— f5a-vwL, <br /> Care of JACK ALEXANDER <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007968 <br /> Facility Name ARS HEARTWATCH <br /> Location 518 BRECK CT <br /> BENECIA, CA 94510 <br /> Phone <br /> Mailing Address 60--/. (o s8 <br /> ROUGH AND READY, CA-959759707 <br /> Care of JACK ALEXANDER <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 1 Facility / Account <br /> Account Name ARS HEARTWATCH (Circle One) <br /> Account Balance as of 21312005: $70.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PRO508162 EE0000988-KASEY FOLEY Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: '$155.00= Amount Paid Date I ! <br /> Payment Type Check Number Re by <br /> REHS: Date I I Account out: Date Z ! 1 as <br /> COMMENTS: <br /> 11phs-ehsgl-ntlappslenvisionslreports15021.rpt <br />