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Date run 11/15/2018 3:33:09F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/15/2018 <br /> Record Selection Criteria: Facility ID FA0013665 <br /> Make changes/corrections 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 OW0010774 New Owner ID <br /> Owner Name DVA Healthcare Renal Care, Inc. <br /> Owner DBA <br /> Owner Address 2000 16TH ST <br /> DENVER, CO 80202 <br /> Home Phone 800-477-1916 <br /> Work/Business Phone 303-405-2100 <br /> Mailing Address 2000 16th Street <br /> Denver, CO 80202 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0013665 10184507 <br /> Facility Name DAVITA MANTECA DIALYSIS CENTER <br /> Location 1156 S MAIN ST <br /> MANTECA, CA 95336 <br /> Phone 209-823-3078 x 44 <br /> Mailing Address 1156 S MAIN ST <br /> MANTECA, CA 95337 <br /> Care of LICENSE DEPARTMENT <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 222-380-080-301 Entail: U <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION r� D D� / <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022822 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name DAVITA MANTECA DIALYSIS CENTER (Circle One) <br /> Account Balance as of 11/15/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? D e <br /> v1921 -HMBP-Reqular-Primary Location PR0521008 EE0000009-NICHOLAS LOEHRER Active Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0518047 EE0000000-HAZ MAT SJC OES Inactive Y N A D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0518046 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4530-LG QUANITY GENERATOR PR0522691 EE0003973-ROBERT MCCLELLON Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534743 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 by <br /> EHD Staff: Date / / Account out: _� Date <br /> COMMENTS: UV (�/2 ! t� �v <br /> Invoice#: <br />