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Datemn .3/11/2013 8:22:02AN SAN JOi_ _ .IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 3/11/2013 <br /> Record Selection Criteria: Facility ID FA0004561 <br /> Make changesicorrections in RED ink. <br /> FILE <br /> INFORMATION <br /> CHANGE(dale) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003468 New Owner ID <br /> Owner Name MERRILL GARDENS LLC <br /> Owner DBA MERRILL GARDENS AT MANTECA <br /> Owner Address 1938 FAIRVIEW EAST AVE STE 300 <br /> SEATTLE, WA 98102 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-823-0164 <br /> Mailing Address 1938 FAIRVIEW AVE EAST STE 300 <br /> SEATTLE, WA 98102 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004561 <br /> Facility Name MERRILL GARDENS AT MANTECA <br /> Location 430 N UNION RD <br /> MANTECA, CA 95337 <br /> Phone 209-823-0164 <br /> Mailing Address 430 N UNION RD <br /> MANTECA, CA 95337 <br /> Care of <br /> Location Code 04 -MANTECA Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 21703017 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 209-823-0164 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004335 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MERRILL GARDENS AT MANTECA (Circle One) <br /> Account Balance as of 3/11/2013: $0.00 <br /> (Circle One) <br /> Transfer to Acti Winaclve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO500066 EE0003474-CHANDRA OM ' e Y N AI D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Nat all site,al 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 anclor Standards and State ardor <br /> Federal Laws. 1� <br /> APPLICANT'S SIGNATURE: 1Pi 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 <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />