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Run by : NORA San Joaquin County PHS/EHD Report #5021 <br /> --------------------FACI Y INFORMATION as of 04 /22. 9 <br /> ------------------------a------------------------ <br /> Make changes/corrections in REO pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER ID: 000674 New Owner IO: 00 <br /> Owner Name: MANTECA HOSPITAL <br /> Owner ODA: MANTECA HOSPITAL <br /> Owner Address: 1205 E NORTH ST <br /> MANTECA , CA 95336 <br /> Home Phone: 209-823-3111 <br /> Soc Sect / Tax IOL: <br /> Ownership Type: 01 CORPORATION <br /> Mailing Address: 1205 E NORTH ST <br /> Care of: MANTECA HOSPITAL <br /> MANTECA , CA 95336 <br /> FACILITY FILE INFORMATION <br /> fiI0: 000853 <br /> Facility lity N Name: O'GCr�� <br /> Location: 1205 E NORTH <br /> MANTECA 95336 <br /> Phone: 209-823-3111 <br /> Nailing Address: PO BOX 191 <br /> Care of: MANTECA HOSPITAL <br /> MANTECA , CA 95336 <br /> Location Code: 04 APR: <br /> 80S District: 003 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0000851 New Account I0: 000 <br /> Nail Invoices to: Facility Nail Invoices to: Owner / Facility / Account <br /> Account Name: MANTECA HOSPITAL (Circle one) <br /> Account Balance as of 04/29/97 : $78 . 00 (Circle one) <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> ------------------------------------------------------------------------------- <br /> 1625 RESTAURANT/BAR 51-111 SEATS PE PRI62944 9151 SARCELLOS ACTIVE Y N A I 0 <br /> 2316 MULTI TANK OLO/NEW FACILITY PR231446 3913 NCCLELLOR ACTIVE 2 Y N A I 0 <br /> 4522 ACUTE CARE FACILITY HEALTH PER PR451104 1968 YOSHIOKA ACTIVE Y N A I D <br /> ------------------------------------------------------------------------------- <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHO hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SI6MATURE: pate <br /> ---------------------- -------------------------------------------------------- <br /> PH Records to be TRANSFERED: x j20.0D Amount Paid Date_/ / <br /> Water System to be TRANSFERED: x tls1.11 = Amount Paid Date_/ / <br /> Payment Type Check t Recvd by <br /> ------------ <br /> REHS or COUNTER SUPV: Date_/_/_ ACCT out:`WDate UNIT/File:_,J_/_ <br /> I <br />