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Facility/Site Mailing Address <br />900 N CHURCH ST <br />LODI, CA 95240 <br />Primary Emergency Contact <br />Administrator <br />(209) 333-1222 (209) 333-1222 <br />Pager Number24-Hour Phone <br />Title <br />Business Phone <br />Tyah Petersen <br />Facility/Site <br />COVENANT CARE LODI LLC <br />900 N CHURCH ST <br />LODI, CA 95240 <br />CERS ID <br />10182417 <br />IdenƟĮcaƟon <br />Operator Phone <br />Dun & Bradstreet <br />Beginning Date <br />Business Phone <br />SIC Code <br />Business Fax <br />Primary NAICS(209) 333-0541(209) 333-1222(209) 333-1222 <br />Covenant Care Lodi LLC dba Arbor Nursing Center Ending Date <br />8051 <br />Owner <br />COVENANT CARE LODI LLC <br />(209) 333-1222 <br />900 N CHURCH ST <br />LODI, CA 95240 <br />Secondary Emergency Contact <br />Maintenance Supervisor <br />(209) 333-1222 (209) 333-1222 <br />Pager Number24-Hour Phone <br />Title <br />Business Phone <br />Jaime Ochoa <br />Billing Contact <br />COVENANT CARE LODI LLC <br />(209) 333-1222 <br />900 N CHURCH ST <br />LODI, CA 95240 <br />Environmental Contact <br />Tyah Petersen <br />(209) 333-1222 <br />900 N. Church <br />Lodi, CA 95240 <br />tpetersen@covenantcare.com <br />ExecuƟve Director <br />Document Preparer <br />AddiƟonal InformaƟon <br />Signer Title <br />Tyah Petersen <br />Name of Signer <br />Locally-collected Fields <br />Some or all of the following Įelds may be required by your local regulator(s). <br />Property Owner <br />R. Thomas Development Inc. <br />Phone <br />(209) 334-5521 <br />Mailing Address <br />P. O. Box 1598 <br />Lodi, CA 95241 <br />Assessor Parcel Number (APN) <br />04125035 <br />Number of Employees <br />155 <br />Facility ID <br />SubmiƩal Status <br />SubmiƩal was Accepted ; Processed on 5/3/2018 by MARTORELLA, DOMENIQUE for San Joaquin County Environmental Health <br />SubmiƩed on 1/3/2018 by Tyah Petersen of COVENANT CARE LODI LLC (LODI, CA) <br />California Environmental ReporƟng System (CERS)Business Owner Operator <br />Printed on 7/18/2018 3:50 PM