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Date run 3/1/2017 12:44:47PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/1/2017 <br />Record Selection Criteria: Facility ID FA0011028 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN / Fed Tax ID <br />Owner ID OW0009028 Case Number: H09183 New Owner ID <br />Owner Name AMERICAN MEDICAL RESPONSE <br />Owner DBA AMERICAN MEDICAL RESPONSE-LODI <br />Owner Address 7575 SOUTHFRONT RD <br />LIVERMORE, CA 94551 <br />Home Phone Not Specified <br />Work/Business Phone 209-948-5136 <br />Mailing Address 400 FRESNO AVE <br />STOCKTON, CA 95203 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0011028 10184047 <br />Facility Name AMERICAN MEDICAL RESPONSE-LODI <br />Location 1709 S STOCKTON ST <br />LODI, CA 95240 <br />Phone 209-368-5776 x0 <br />Mailing Address 400 FRESNO AVE <br />STOCKTON, CA 95203 <br />Care of AMERICAN MEDICAL RESPONSE <br />Location Code 02 - LODI Alt Phone <br />BOS District 004 - WINN, CHARLES Fax <br />APN 06219022 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 AR0018028 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name AMERICAN DIC L SQ NSE (Circle One) <br />Account Balance as of 3/1/2017: $32 0 <br />(Circle One) <br />Transfer to Active/lnactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Locatio PR0520620 EE0008709 - JAMIE LIMA Active Y N A( If <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513316 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511028 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO533273 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT:, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility <br />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 Ordinance Codes and/or Standards and State anc/or <br />Federal Laws. <br />APPLICANT'S 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 by <br />EHD Staff: 1(1(`2 Date / --7—Account out: 14 Date <br />COMMENTS: <br />Invoice #• <br />�tS Addre�S <br />