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Home My WebLink About1729 26TH STREET (2),_ li~idocs - Uniform Documents ~~~~r~~~.~ ~~~~r'~~~~ ~~~~~~ ~~~'~~~~r~ ~#~r~~~~ Page 1 of 2 Viewing/Updating Facility Inforrnation After modifying the facility information below, click 'Update Facility' ta update the database. No Users Have Access to this Facility I. IDENTIFICATION FACIIITY ID#: BEGINNING DATE (MM/DD/YYYY) ENDING DATE (MM/DD/YYYI~ 15 ___~^' 021 i... 002298 __~ ._..... w_._...__.__.__._. _.r._..__ _._.__._..; ~ BUSINESS PHONE (#illf) #t~Ji-#iiR# BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) x###!t PEDERSEN DDS RAYMOND _......... ................._._...._....._.......... ....._....._.................................___...... ......................................_.. _._._._.._....... _.._ .. .~._.r.._~ ., ; 6613249523 ~ ~ BUSINESS SITE ADDRESS: 1729 26TH ST __.______~.......a_.~___..~._ ~__..~__.._.....____.~__ CITY: ~___._. ___~._...._._.~..._.. ~ _.w..__._.____.__._____.___~._...~._.._.._.___ STATE: ZIP CODE: BAKERSFIELD ___._.._~_ .............._...._..........._...........___ . . . .~_ CA 93301 `: : ; .. _ ._ ....._........................... _ ... DUN & BRADSTREET: .........._. _.._.................__..._.._................. SIC CODE (4 digit #): 8021 ~~ COUNTY: KERN _.~.__. ~__._~__ _ .. . ~ __ _~.. _. _._.~..~._...___._.~........__~,.. BUSINESS OPERATOR NAME: _.....~. BUSINESS OPERATOR PHONE: (#!Ik) tl#If-tl#t~H x#N## RAYMOND PEDERSON ._..._.~ __._~......._~_. ~ _.__.__.______.~ ; _.__.: __ ~ __.._......~___ __.~_.._._..~ II. BUSINESS OWNER OWNER NAME: OWNER PHONE: (##~t) #ftll-llitN# x#### RAYMOND PEDERSEN ~.., ......~ ..... ...._. _ . .. _...._.. . . : 6613249523 ~ ~ ... _ OWNER MAILING ADDRESS: _...._ _ __......... __... . _ .. 1729 26TH ST CITY: STATE: ~ ZIP CODE: BAKERSFIELD ` _~ ~_..__ __.~_.__ ~___~ CA ~ 93301 ~ ~___.__.~~~~ ~ __.__.__..~._~______..___.._~ III. ENVIRONMENTAL CONTACT CONTACT NAME: CONTACT PHONE: (#Nlt) HN#-!~### RAYMOND PEDERSON .. xNillt# . .. _..._ _; 6613249523 ~ _..,,~, _ ._~..... . _ ......... . ._......~ CONTACT MAILING ADDRESS: 1729 26TH ST W~~~~ ~ ~~ CITY: STATE: ~µ~ Y~~~~^~ W~~µ~ ZIP CODE: .~~ ELD ~ .~_ERSFI CA ' 93301 ~ _._. ~.~...._........~., ~ __~~...__.___. .~_~._._ W_.~_~ IV. EMERGENCY CONTACTS -PRIMARY- -SECONDARY- https://unidocs.ecointeractive.com/user/facility edit.asp?facility id=15-021-002298 11/26/2008 iTiiidocs - Uniform Documents NAME: RAYMOND PEDERSON TITLE: DDS ......................._~..,.............,.____""__._`__.-...~....~..~..~.........._.........i BUSINESS PHONE: (k##) ##Jt-tt#Mt! x#### 6613249523 ; ~~._._~._........._..........__..~..~ _.._._~..~._._. 24-HOUR PHONE: ({t##) (###-tl#N# x##q# ~ .~.....~..~...........,., ~.__m._._. ..,,.,~....~...a PAGERk: i ADDITIONAL~LOCALLY COLLECTED INFORMATION: Page 2 of 2 NAME: RAYMOND PEDERSON ' TITLE: DDS ~.._. . ....._. ._... ..~.__.....__.___.........J BUSINESS PHONE: (#!!lf) ti##-###~ x#l!#tl 6613249523 _.._ ............. ._--.~.. _._~~~....~......................................__ 24-HOUR PHONE: (#li#) ii##-1!#llli xk#~Ik ~.....~.. ~ PAGER#: .__~..._~~ _ _~ _..__.__~____ __ ~! Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certity under penaltyof law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. DATE: (MM/DD/YYW) NAME~OF SIGNER: ~ ~ ~~ NAME OF DOCUMENT PREPARER: TITLE OF SIGNER: ~~ m mµ~ ~TT ~~ 3 UPCF(1/99 revised) Back _#o._Activity._Sel_ection OES FORM 2730 (1 /99) home ~ what'..s..._n~w. ~ m.e...mber.r,._~g..e..n.~i,~&. ~ docu_ment~ ~.n...d...r~rvi_Ges ~ s~.~rFh...~nid.OGS ~.G..ont.a...ct. us related._links ~ training and meetings For comments or questions regarding the HMIS project, contact the Qnline._D.~t~.p.as.e._.A. dm.,.ini~tr~tpr.. hosted by City_of Palo_Alta https://unidocs.ecointeractive.com/user/facility edit.asp?facility id=15-021-002298 11/26/2008 ¢~ ~Cusinmer'ID 39 °• J qalance; etail; ~ Delinpuent No1 ~ ~ Involce Inqulry ~~ ~.~..MiStn,IlanE0ti5 ~ CustomerType ~~ ~ ~ , `: ~ cM . ,~..~T+~~~~ r r>:. ~ ti i g Custoeer ID~/ Status 39358~/ Activa Naoe ' b '~~ ~ :. ~ PEDERSEN D05 PAYHINdD ^~ ~;i ~ ~Nane type ~»~~~ ~ ~Compeny~ `~ ~ ~ ~ ~ E h ~Custoeer ;type s~ ~~~ f HJVIi~t916YTAL SERVICES ~ ~, Addre59~`l1ne~'ane ' ~~.1729 26TH Sf ~" ' Address~linei'tvo a ! ~ -~ ~ ~ ~^ a ~ ~ E° ~ C~tp~/~Statefr/.Zip~ "r~ ~BpK92SFI9_D CA g33p1 ~'~ ~' hu~ _ ~ ~ ~w~~. ~ _ ..~ .. . ... ~ ~ ~~ E Billi g Criterfa ~a ~~ ~ ; ~ ~ ~ ~ ~.' Allow cost cha~ge break No ~~ .~r ~ ~ ~ Cesh~'only ~~~s ° ~ , ~ r 'r~ r ~ ~ Bank'draft ~ ~ NoA~ ~ '~~ ~ ~ i Tex~ezempt / Exemption~num~Eer Alo ~~ ~~~ ~ ~ Exciude penalties ~ ~ ~ Use customer~typ~~ ~: ~EKClude finance charges ~USe customer.~type ~ ~ ~ s;~~="9„^«..r,~' '~^~^.I~ ~~ ~ . ~,~~ -..~at.