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Date run 11/29/2016 3:25:11P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by DONNA Facility Information as of 11/29/2016 <br /> Record Selection Crean.: Facility 10 FA0018754 <br /> Make changesicorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax to <br /> Owner ID OW0015421 New Owner ID <br /> Owner Name AMERICAN MEDICAL RESPONSE <br /> Owner DBA AMERICAN MEDICAL RESPONSE <br /> Owner Address 400 FRESNO ST <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-948-5136 <br /> Mailing Address 400 FRESNO ST <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018754 10186971 <br /> Facility Name AMERICAN MEDICAL RESPONSE <br /> Location 400 S Fresno St <br /> Stockton, CA 95203 <br /> Phone 209-948-5136 x <br /> Mailing Address 400 FRESNO ST <br /> STOCKTON, CA 95203 <br /> Care of AMERICAN MEDICAL RESPONSE <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPLIDLIA, CARLOS Fax <br /> APN 14529006 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0033299 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account <br /> Account Name AMERICAN MEDICAL RESPONSE (Circle One) <br /> Account Balance as of 11/29/2016: $193.00 <br /> (Circe One) <br /> Transfer to Adived1nactve <br /> Progran/Element and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 1921 -HMBP-Regular-Primary Location PRO527670 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 4530-LG OUANITY GENERATOR PRO531197 EE0003973-ROBERT MCCLELLON Active Y N A D <br /> 4557-MED WASTE LIMITED HAULER PR0506412 EE0003973-ROBERT MCCLELLON Inactive Y N A 1 0 <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534072 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent d same,acknowledge that all site,and/or picked specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on Nis form. I also certify Nat all operations will be Performed in accordance with all applicable Ordinance Codes anNor Standards and Stale anNor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Ty Check Number Received y <br /> EHD Staff: 1 _ Date�/ ! (0. Account out: Date �2-/�/� <br /> COMMENTS: <br /> voice <br /> lAtAb? bt ��t j •`fit CorY�tncJ l.,�� 0.rc�1$.e� o�cra� �r�"l�k(III rvta"I "' <br /> Fresno Avea Wes{ LO-INP- or �'`e�V"e `�^ C6�""� <br /> oy' k ^t 1ca4se as�+kse <br />