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Date run 12130!2004 4:03:09F SAN JC 7UIN COUNTY ENVIRONMENTAL HEAL TH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by _ + %� <br /> Facility Information as of 1213012emP4 <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 518 BRECK CT <br /> BENECIA, CA 94510 <br /> Home Phone 925-952-9265 <br /> Work/Business Phone Not Specified <br /> Mailing Address 15252 SURE BET RD H477 Mr—tCbq LJ V I E <br /> GRASS VALLEY, CA 959458678 4- �U7 <br /> Care of ,LACK 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 15252 SURE BET RD <br /> GRASS VALLEY, CA 959458678 <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 lD AR0014787 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ARS HEARTWATCH (CirdeOne) <br /> Account Balance as of 1213012004: $70.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PRO508162 EE0000968-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,and/or 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date / 1 <br /> Program Records to be TRANSFEREO: *$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: *$155.00= Amount Paid Date <br /> ! ! <br /> Payment Type Check Number Re I y_ <br /> REHS: Date ! 1 Account out: Date L21 ! <br /> COMMENTS: <br /> 11phs-ehsql-ntlappslenvisionslreports15021.rpt <br />