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Date nun 12/5/2008 8:59:16AN SAN JOA'�'UIN COUNTY ENVIRONMENTAL HEALTxl�DEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> tr,.o Facility Information as of 12/5/200"F-6 <br /> Record Se$ection Criteria: Facility ID FA00114109 <br /> Make changes/corrections in RED ink or pencil. <br /> "L INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION ~"'' SSN/Fed Tax ID <br /> Owner ID OW0011 171 New Owner ID <br /> Owner Name HOUSECALLS HOME HEALTH AGENCY <br /> Owner DBA HOUSECALLS HOME HEALTH AGENCY <br /> Owner Address 1250 S WILSON WAY#B <br /> STOCKTON, CA 952057054 44 q-15--2-0 S5 <br /> Home Phone 209-952-8015 <br /> Work/Business Phone 209-8$7-9332 <br /> Mailing Address 1250 S WILSON WAY#B <br /> STOCKTON, CA 952057054 <br /> Care of SAXTON, CURTIS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014109 <br /> Facility Name HOUSECALLS HOME HEALTH AGENCY <br /> Location 1250 S WILSON WAY#B /O 5p AV Sf' <br /> STOCKTON, CA 952057054 fv gS3-o S <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 <br /> Day Phone 209-952-8015 <br /> Night Phone 209-887-9332 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023857 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name HOUSECALLS HFrdl <br /> ALTH AGENCY (Circle One) <br /> Account Balance as of 121512008: $77.001 g!g <br /> (Circle One) <br /> ProgramlElemeni and Description R Em ye�D a ame Status Transfer r Activeleactve <br /> New Owners Delete <br /> 4557-MED WASTE LIMITED HAULER PREE 988-KASEY FOLEY Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSlEHD hourlycharges associated with this <br /> facility or activity witl be billed to the party identified as the OWNER on this form. i also certify that all ope{ations 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 1-2 1 0 Or <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type ✓ Check Number A l D t'Sia Received by LI6._-.--- <br /> REHS: Date / 1 Account out: L� Date k?— / a S 1 0 ,9 <br /> COMMENTS- <br /> Ilphs-ehsq I-ntlappslenvisionslreports15021.rpt <br />