BILLING - Laserfiche WebLink

Home Browse Search

Date run 10/31/2014 1:19:14PRepo"#5021 SAN JO�JIN COUNTY ENVIRONMENTAL HEA' DEPARTMENT Pagel Run by Facility Information as of 10/31/2014-- Record Seleclion Cataria: Facility ID FA0009105 Make changesicorrections in RED ink. INFORMATION CHANGE(date) OWNERSHIP CHANGE(date) OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID Owner ID OW0007105 Case Number: H01216 New Owner ID Owner Name COVENANT CARE LODI LLC Owner DBA COVENANT CARE LODI LLC Owner Address 900 N CHURCH ST LODI, CA 95240 Home Phone 209-333-1222 Work/Business Phone 209-333-1222 Mailing Address 900 N CHURCH ST LODI, CA 95240 care of MCGARY, DOREEN, EXEC DIRECTOR FACILITY FILE INFORMATION Facility ID/CERS ID FA0009105 10182417 Facility Name COVENANT CARE LODI LLC Location 900 N CHURCH ST LODI, CA 95240 Phone 209-333-1222 x Mailing Address 900 N CHURCH ST LODI, CA 95240 Care of Covenant Care Lodi LLC dba Arbor Nursing CI Location Code 02 - LODI Alt Phone BOS District 004-VOGEL, KEN Fax APN 04125035 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name DOREEN MCGARY Title EXECUTIVE DIRECTOR Day Phone 209-333-1222 x4813 Night Phone 209-662-0380 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0016105 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account Account Name COVENANT CARE LODI LLC (Circle One) Account Balance as of 10/31/2014: $0.00 (Circle One) Transfer to Active/Inacive PrograrvElement and Description Record ID Employee ID and Name Stews New Ownl Delete 1628-LICENSED HEALTH CARE FACILITY PR0527289 EE0004589-KADEANNE LINHARES Active Y N A I D 1921 -HMBP-Regular-Primary Location PRO519385 EE0008709-JAMIE DE LA ROSA Active Y N A I D 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511393 EE0000000-HAZ MAT SJC OES InactivE Y N A I D 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509105 EE0000000-HAZ MAT SJC DES InactivE Y N A I D 4524-SKILLED NURSING FACILITY PR0536162 EE0002622-BENJAMIN ESCOTTO Active Y N A I D ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532409 Inactivif Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor protect specific,PHS/EHD hourly charges associated with this 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 Ordinance Codes ander Standards and State andor Federal Lewis APPLICANT'S SIGNATURE: Date / I Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by REHS: Date /_/ Account out: Date COMMENTS: