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Date run 9/26/2014 11:35:17AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9126/2014 <br /> Record Selection Criteria: Facility ID FA0012722 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0009452 New Owner ID <br /> Owner Name COMMUNITY MEDICAL CENTERS INC <br /> Owner DBA <br /> Owner Address 7210 E MURRAY DR <br /> STOCKTON, CA 95210 <br /> Home Phone 209-373-2800 <br /> Work/Business Phone 209-940-7206 <br /> Mailing Address PO BOX 779 <br /> STOCKTON, CA 95201 <br /> Care of LOPEZ, DAVID <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0012722 <br /> Facility Name LAWRENCE FAMILY CENTER & CLINIC <br /> Location 721 CALAVERAS ST <br /> LODI, CA 95240 <br /> Phone 209-368-2212 <br /> Mailing Address PO BOX 779 --Th a.C. I✓e LtS5 7 02e y- <br /> STOCKTON, CA 952010779 <br /> Care of LAWRENCE FAMILY CENTER/CLINIC <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 04124006 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 AR0021209 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name LAWRENCE FAMILY CENTER & CLINIC (CirdeOne) <br /> Account Balance as of 912612014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PR0516633 EE0003973-ROBERT MCCLELLON Active Y N A Q D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that W site,ancilor project specific,PHSlEHO hourly charges associated with this facility <br /> or activity wlii 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 andlor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number t j d by <br /> REHS: n i Date 10 1 -& 1 _ Account out: Date !�p alp !14 <br /> COMMENTS: <br />