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ate run 11/29/2006 2:17:39PI SAN JUIN COUNTY ENVIRONMENTAL HEISH DEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> Facility Information as of 11/29/2006 <br /> Record Selection Criteria: Facility ID FA0007404 <br /> Make changes/corrections in RED ink or pencil. <br /> HL <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0006115 New Owner ID <br /> Owner Name FREMONT VETERINARY CLINIC <br /> Owner DBA FREMONT VETERINARY CLINIC <br /> Owner Address 2223 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Home Phone 209-465-7291 <br /> Work/Business Phone 209-465-7291 <br /> Mailing Address 2223 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Care of FREMONT VETERINARY CLINIC <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007404 <br /> Facility Name FREMONT VETERINARY CLINIC <br /> Location 2223 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Phone 209-465-7291 <br /> Mailing Address PO BOX 1952 02].a-3 11.r fit <br /> STOCKTON, CA 95201 5f Ly--fTn L-Pt Sa-O S — �--7 <br /> Care of ROBERT LINDSTROM DVM <br /> Location Code 01 - STOCKTON APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0011143 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FREMONT VETERINARY CLINIC (Circle One) <br /> Account Balance as of 11/29/2006: $72.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PR0506410 EE0000988-KASEY FOLEY Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD 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 <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />