Laserfiche WebLink
Date run 6/15/2017 3:40:52PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/15/2017 <br /> Record Selection Criteria: Facility ID FAD024104 <br /> Make changesicorrections 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 OW0022614 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 782 E Harding Way <br /> Stockton, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID!CERS ID FA0024104 10737949 <br /> Facility Name Dignity Health Medical Group Stockton <br /> Location 782 E Harding Way <br /> Stockton, CA 95204 <br /> Phone 209-946-6810 x <br /> Mailing Address 782 E Harding Way <br /> Stockton, CA 95204 <br /> Care of Dignity Health MedicalGroup 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 AR0044774 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name Lisa Nordell (Circle One) <br /> Account Balance as of 611512017: $0.00 <br /> (Circle One) <br /> Transferto ActiveAnactve <br /> PrograndElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO541994 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,andfor project specific,PFISIEFID 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 andror Standards and Slate andlor <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 <br /> EHD Staff: r'\ ' Date- 7 Account out Date <br /> COMMENTS: Invoice#: ����� <br /> L rtw�A Pr za J c,y Pe, Lt 0,511 �tAt,n17 - Aw,/10-, <br />