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Date run 6115/2017 3:02AIPA SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT Report 95021 <br /> Run by Paget <br /> Facility Information as of 6115/2017 <br /> Record Selection criteria: Facility ID FA00241 03 <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 : SSKI Fed Tax ID <br /> Owner ID OW0022612 New Owner ID <br /> owner Name Dignity Health Medical Foundation <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-946-6810 <br /> Mailing Address 1901 N California St <br /> Stockton, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0024103 10737946 <br /> Facility Name Dignity Health Medical Group Stockton <br /> Location 1901 N California St <br /> Stockton, CA 95204 <br /> Phone 209-946-6810 x <br /> Mailing Address 1901 N California St <br /> Stockton, CA 95204 <br /> Care of Dignity Health Medical Group Stockton <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail. <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0044768 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner f Facility ! Account <br /> Account Name Lisa Nordell (circle One) <br /> Account Balance as of 611512017: $0.00 <br /> (circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record lD Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0541993 EE0001421 -STACY RIVERA Active 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,PHS1EHO 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 a[[operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andYor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE. Date ! 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! ! <br /> Water System to be TRANSFERED Amount Paid Date ! 1 <br /> Payment Type Check Number _ Received by .y / 1 <br /> EHD Staff: V, Z5- Date _l 7 1 1 Account out: Date 1 , 7 1 <br /> COMMENTS: _ Invoice#: �-1� <br /> - <br /> _ r ! �! <br />