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FF <br /> Date run : 1/8/01 9:28:42AM SAN AQUIN COUNTY PUBLIC HEALTH SER 'ES Report #: 0002 <br /> Run by LBROWN Facility Information as of 1/8/01 �./ Page #: 1 <br /> Record Selection Criteria: Facility ID FA0007679 <br /> Record 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: OW0006342 New Owner ID <br /> Owner Name: KOEHMSTED, ORLIN <br /> Owner DBA: DELTA RADIOLOGY MED GRP <br /> Owner Address: 1121 W VINE ST <br /> LODI, CA 95240- <br /> Home Phone: Not Specified <br /> Work/Bussness Phone: 209-466-5027 <br /> Mailing Address: 1121 W VINE ST <br /> LODI, CA 95240- <br /> care of: ORLIN KOEHMSTED <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0007679 <br /> Facility Name: DELTA RADIOLOGY MED GRP <br /> Location: 2420 N CALIFORNIA ST 7 <br /> STOCKTON, CA 95204 <br /> Phone: 209-466-5027 <br /> Mailing Address: 2420 N CALIFORNIA ST <br /> STOCKTON, CA 95204- <br /> Cam of: ORLIN KOEHMSTED <br /> Location Code: 01 -STOCKTON APN; <br /> BOs District: 002 - MARENCO, DARIO SIC code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0013267 New Account ID:: <br /> Mail Invoices to: Facility Mail Invoices to: Owner/Facility/Account <br /> Account Name; DELTA RADIOLOGY MED GRP (Circle One) <br /> Account Balance as of 1/8/01: $0.00 <br /> (Circle One <br /> UST(s) Transferto Active/Inacty <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2233-HAZARDOUS WASTE CESQT FACILITY PR0506944 EE0000418-KITH Inactive Y N 1 <br /> 2213-HAZ WASTE CE FAC STATE SERVICE FEE PRO506945 EE0000418-KITH Inactive Y N r1 1 <br /> 2399-UNIFIED PROGRAf4 FAC STATE SERVICE F PR0506946 EE0000418-KITH Inactive Y N i4 T <br /> I Nn !dnA.Q.Q. (7CIILYp{B4 . �Ro61!/4 � t�� I4 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned or?ner,op ror agent?,f-same,aeknawle$e that aU site,and/orpro'ect <br /> specific,PHSIEHD hourly charges associated with this facility or activity will be billed to the part u(entr/r'ed as the BILLINGPARTYon thisjorm I <br /> also cert6 that all operations will be perfomred in accordance with all applicable Ordinate Codes and/or Standards and State and/or Federal Laws <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: "$0.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: •$150.00= Amount Paid Date / / <br /> Payment Type Check Number Receipt Number Received by <br /> V RENS: Date Account out: i,b Date 0 1 O /0 1 <br /> 1.0.0.89.00 <br />