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Date run : 915/00 12:13:34PM SAN "IUIN COUNTY PUBLIC HEALTH SER` S Rupert #: 000; <br /> Run by LTURKATTE �� Facility Information as of 916100 �� <br /> Record Selection Criteria: Facility ID FA0007968 <br /> Re ID <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- c::- /L1"Ifl I3AY. Cry 9510/7 _ <br /> Home Phone: 800-418-7108 <br /> WorklBussness Phone: Not Specified <br /> E���Mailing Address. -518--gfZffeK-$T <br /> 4 -1-E3� <br /> VE <br /> Care of: ARS HEARTWATCH SEP 0 B 2000 <br /> FACILITY FILE INFORMATION ENVIRONMENT HEALTH <br /> Facility ID: FA0007968 PERMIT/SERVICES <br /> Facility Name: ARS HEARTWATCH <br /> Location: 518 BRECK CT <br /> BENECIA, CA 94510 <br /> Phone: 800-418-7108 <br /> Mailing Address: 598-13REC-K--CT- S l <br /> B€N GIA C-7k-94-5t•O- <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 /> Mai!Invoices to: Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name: ARS HEARTWATCH (Circle One) <br /> Account Balance as of 916100: $0.00 <br /> One) <br /> UST(s) Transfer tHAtIT <br /> actve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Ownerte <br /> 4557-MED WASTE LIMITED HAULER PR0508162 EE0000988-FOLEY Inactive Y N e�' A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agentof same,acknowledge that all site,and/or <br /> project specific,PHSIEHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this <br /> form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANT'S SIGNATURE: % Date ! G ! D J <br /> Program Records to be TRANSFERED: "$0.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED/ `$150.00= Amount Paid unDate 1 Ir /0i) <br /> Payment Type Check Number 2L 1S Receipt Number Received by ?vA-- <br /> REHS: Date 1 I Account out: Date <br /> ` LfW�D75 <br /> 44�q <br /> 1.0.0.89.00 <br />