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Run by : NOPA San Joaquin County PHS /EH0 Report 1#5021 <br /> _____FACI— Y INFORMATION a5 of 04 /2*7 <br /> --------------- ------------------------_---------------------------- <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date,: <br /> OWNERSHIP CHANGE (date): <br /> OWNER ID: 000674 New Owner ID: 00 <br /> Owner Name: MANTECA HOSPITAL <br /> Owner DBA: MANTECA HOSPITAL <br /> Owner Address: 1205 E NORTH ST <br /> MANTECA , CA 95336 <br /> Home Phone: 209-823-3111 <br /> Sac Sect / Tax IDI: <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 /> FACILITY ID: 000853 y— <br /> Facility Name: /['� ✓� �rG <br /> Location: 1205 E NORTH U <br /> MANTECA 95336 <br /> Phone: 209-823-3111 <br /> Mailing Address: PO BOX 191 <br /> Care of: MANTECA HOSPITAL <br /> MANTECA , CA 95336 <br /> Location Code. 0 4 APN: <br /> BOS district: 003 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0000851 New Account ID: 000 <br /> Nail Invoices to: Facility Nail Invoices to: Owner / Facility J Account <br /> Account Name: MANTECA HOSPITAL (Circle one) <br /> Account Balance as of 04 /29/97 : $78 . 00 (Circle one) <br /> Record USI s) Transfer to Activate / Inactivate <br /> P/E Description IO Employee Status Linked new owner? Delete <br /> ------------------------------------------------------------------------------- <br /> 1625 RESTAURANT/BAR 51-119 SEATS PE PRI62344 9157 BARCELLOS ACTIVE Y N A I 0 <br /> 2316 MULTI TANK OLD/NEW FACILITY PR231446 3973 MCCLELLON ACTIVE 2 Y N A I D <br /> 4522 ACUTE CARE FACILITY HEALTH PER PR451114 1968 YOSHIOKA ACTIVE Y N A I 0 <br /> ------------------------------------------------------------------------------- <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, acknowledge that all site and/or . <br /> project specific PNS/END hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY an this form. I also certify that all operations will be performed in accordance with all applicable SAN 3OAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / <br /> ------------------------------------------------------------------------------- <br /> PR Records to be TRAISFERED: x X20.99 = Amount Paid Date—/—/ <br /> Water System to be TRANSFERED: x $150.90 Amount Paid Date <br /> Payment Type Check 4 Recvd by <br /> REHS or COUNTER SUPV: Date f rr ACCT out: i(, TT �Date� UNIT/File; / _/—__— <br />