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Dateruz;i 12/11/01 11:43:29AM $ OAQUIN COUNTY PUBLIC HEALTH SF'- `:.ES Report #'. 5023 <br /> Page #: 1 <br /> Run by Facility Information as of 12/11/01 <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: 800-590-4046 <br /> Work/Business Phone: 650-712-9639 <br /> Mailing Address: PO BOX 1119 <br /> HALF MOON BAY, CA 94019 <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: 800-590-4046 <br /> Mailing Address: PO BOX 1119 <br /> HALF MOON BAY, CA 94019 <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 1 Facility!Account <br /> Account Name: ARS HEARTWATCH (Circle One) <br /> Account Balance as of 12111101: $67.00 <br /> (Circle One) <br /> Transfer to Act' Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? De to <br /> 4557-MED WASTE LIMITED HAULER PRO508162 EE0000988-KASEY FOLEY Active Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 I ilii <br /> Water System to be TRANSFERED: "$150.00= Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> RENS: Date 1 1 Account out: Date- 17-11�� <br /> COMMENTS: <br /> z� , <br /> l2ficor ��ea$.e Inas `,.�te� <br /> If)C) known ,Cot- l�usl"ss , <br /> 11Phs-ehsq knthappslEnvisionslReports15021.rpt <br />