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Date run 4/4/2007 11:49:24AM SAN JUIN COUNTY ENVIRONMENTAL HEOH DEPARTMENT Report#W21 <br /> Run by 0 Paget <br /> Facility Information as of 4/4/2007 <br /> Record Selection Criteria: Facility ID FA0018090 <br /> Make changes/corrections in RED ink or pencil. <br /> FIL V INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW 0005885 New Owner ID Mlinrp, <br /> Owner Name DAVITA INC <br /> Owner DBA <br /> Owner Address 1423 PACIFIC AVE <br /> TACOMA, WA 98402 <br /> Home Phone Not Specified <br /> Work/Business Phone 800-477-1916 <br /> Mailing Address PO BOX 2037 <br /> TACOMA, WA 98401 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018090 <br /> Facility Name DAVITA LODI DIALYSIS CENTER <br /> Location 1610 W KETTLEMAN LN STE D <br /> LODI, CA 952423731 <br /> Phone 209-334-9888 <br /> Mailing Address 1640-VV-KE-TT-L-EldAN-Lt4-ST-E-& SLG o Q rd <br /> 2 <br /> Care of <br /> Location Code 02- LODI APN:05826040 <br /> BOS District 004-VOGEL, KEN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031818 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DAVITA LODI DIALYSIS CENTER (Circle One) <br /> Account Balance as of 4/4/2007: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4530-LG QUANITY GENERATOR PR0526718 EE0000988-KASEY FOLEY Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. t <br /> APPLICANT'S SIGNATURE: Se e- 0A Date Lk / L� /01 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date / / Account out: Cr Date Ll/—L1, Q <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />