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Date run 11/17/2015 9:18:53A SAN JOA 'N COUNTY ENVIRONMENTAL HEALT DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 11/17/2015 <br />Record Selection Criteria: Facility ID FA0009746 <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN /Fed Tax ID <br />Owner ID OW0007746 Case Number: H05318 New Owner ID <br />Owner Name Ventas INC <br />Owner DBA VALLEY GARDENS HEALTHCARE & REHAE <br />Owner Address 1517 KNICKERBOCKER DR <br />STOCKTON, CA 95210 <br />Home Phone Not Specified <br />Work/Business Phone 502-596-7300 <br />Mailing Address 1517 E KNICKERBOCKER DR <br />STOCKTON, CA 95210 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0009746 10182859 <br />Facility Name Kindred Transitional Care and Rehabilitation V <br />Location 1517 KNICKERBOCKER DR <br />STOCKTON, CA 95210 <br />Phone 209-957-4539 x <br />Mailing Address 1517 E KNICKERBOCKER DR <br />STOCKTON, CA 95210 <br />Care of Kindred Transitional Care and Rehabilitation V <br />Location Code 01-STOCKTON Alt Phone <br />BOS District 003 - BESTOLARIDES, STEVE Fax <br />APN 09056004 EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name KINDRED TRANSITIONAL CARE & REHAB <br />Title <br />Day Phone 209-957-4539 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016746 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name Kindred Transitional Care and Rehabilitation Valley G (Circle One) <br />Account Balance as of 11/17/2015: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1628 - LICENSED HEALTH CARE FACILITY PR0527312 EE0009488 - JEFFREY WONG Active Y N A _ I D <br />1921 - HMBP-Reqular-Primary Location PR0519843 EE0000006 - HAZA SAEED Active Y N A ",I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512034 EE0000000 - HAZ MAT SJC IDES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509746 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />4524 - SKILLED NURSING FACILITY PR0536182 EE0002622 - BENJAMIN ESCOTTO Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533443 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility <br />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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: * $25.00 = Amount Paid Date / / <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received <br />ll by <br />�i <br />EHD Staff: �}�a 5F Date ��/_� /� Account out: L t Date �/ 190; <br />0; <br />COMMENTS: <br />Invoice #: <br />