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Date run 4/1/2005 11:04:17AM SAN JO _"UIN COUNTY ENVIRONMENTAL HEAD rH DEPARTMENT Report#5021 <br /> Run by 1273 %4./ Paget <br /> Facility Information as of 411/20 <br /> Record Selection Criteria: Facility fD 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 DSA ARS HEARTWATCH <br /> Owner Address PO BOX 1658 <br /> ROUGH AND READY, CA 959751658 <br /> Home Phone 925_952_9265 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1658 <br /> ROUGH AND READY, CA 959751658 <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 PO BOX 1658 <br /> ROUGH AND READY, CA 959751658 <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 / Facility I Account <br /> Account Name ARS HEARDNATCH (Circle One) <br /> Account Balance as of 41112005: $70'00 <br /> (Circle One) <br /> Transferto Activellnactve <br /> Program/Element and Description Record to 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 or same,acknowledge that all site,and/or project specific,PHSIEHD 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 I ! <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: "$155.00= Amount Paid Date 1 1 <br /> Payment Type Check Number Received y <br /> REHS: Date 1 I Account out: Date 1 I�� <br /> COMMENTS: <br /> NO b- <br /> 11phs-ehsq I-ntlappslenvisionslreports15021.rpt <br />