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Dle run 10/1/2009 9:55:41AN SAN JOA 'IN COUNTY ENVIRONMENTAL HEAT'r'v DEPARTMENT Report#5021 <br /> Run by 4006 %,.� Facility Information as of 1011120er'*" Pagel <br /> Record Selection Criteria: Facility ID FA0014109 <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID OW0011171 New Owner ID <br /> Owner Name HOUSECALLS HOME HEALTH AGENCY <br /> Owner DBA HOUSECALLS HOME HEALTH AGENCY <br /> Owner Address 1050 N UNION ST <br /> STOCKTON, CA 95205 <br /> Home Phone 209-952-8015 <br /> Work/Business Phone 209-887-9332 <br /> Mailing Address 1050 N UNION ST <br /> STOCKTON, CA 95205 <br /> Care of SAXTON, CURTIS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014109 <br /> Facility Name HOUSECALLS HOME HEALTH AGENCY <br /> Location 1050 N UNION ST <br /> STOCKTON, CA 95205 <br /> Phone 209-952-8015 <br /> Mailing Address 1050 N UNION ST <br /> STOCKTON, CA 952054118 <br /> Care of SAXTON, CURTIS <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SAXTON, CURTIS <br /> Title ¢ c� <br /> Day Phone �{� L 3 <br /> Night Phone 209_887-9332 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023857 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name HOUSECALLS HOME HEALTH AGENCY (Circle One) <br /> Account Balance as of 10/1/2009: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PRO518736 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,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 Ordinate Codes andlor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: r,??�� ` Date ( 1 3Z) 10 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid ��Date <br /> Payment Type Check Number Received by <br /> RENS: Date ! ! Account out: Date 1 ! <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> SEP 3 a 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> TH DEPARTMENT <br /> Ileh-envlenvisionlreports15021.rpt H�- <br />