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11V12J/21JUTt 11:1b 1b`J4b4b1Jb LNV1 NIH♦, HtgLIh 11PAt nsiO3 <br /> 9V23l2008 41:13 37'AI SAN A woQUIN COUNTY ENYIRONMENTA,L HEA <br /> +� 40M _ >,�DEPARTMENT ,repertMl60z, <br /> Facility Information as of 9/23/2008 peat <br /> Reoara mon tarMerlc Fepay II} FA000SM 05 <br /> Make t hMW@1C0MCtlons in RED ink or pencil. <br /> INFORMATION CHANCE(date) <br /> OWNER FILE INFORMATION �OWNFMSHIP CHANGE(dap <br /> Owner ID �� V E <br /> OW0007105 Case Number: H01216 New A <br /> owner Naltte A G 9 eel�h f r.J <br /> Owner Den ARBOR.CONVALESCENT HOSPITAL <br /> Owner Address S 1 rj GO Tl . <br /> Home PhoneSIJ 46�5�-� CA J0A <br /> Not Spt�lffed 5123 RS <br /> Wommueross Phone 209.958--9600 5 <br /> II�eNiras Addrttea - ; <br /> 561 i ccj'T�..6 v <br /> �L� GA-05049- <br /> 6M , <br /> cage of ' <br /> FACILOY FILE INFORMATION <br /> Facility ID FAbW9105 <br /> t <br /> F201iq►Dame ARBOR CONVALESCENT HOSPITAL �� <br /> �r- <br /> Locetlon 900 N CHURCH ST <br /> LODI, CA 95240 <br /> Phone 20G-333-1222 x0 <br /> MeilingAddrpre 900 N CHURCH ST <br /> LODI, CA 95240 <br /> I Care of <br /> Westton Cade 02-LODI Alt Phone <br />' etas District 004-VOG EL,KEN Fax <br /> APN 04125035 t:MaW <br /> EMERGEKCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> D2Y Phone 209-333-1222 x0 <br /> Night Phone x0 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD AR001S105 NewAccount ID: <br /> Mail Ilwoices to Feaiiity Map Invoices to. Owner I Facility / Account <br /> Acmunt Name ARBOR CONVALESCENT HOSPITAL tcwx Onll <br /> Account Balance as of 9/23/2MB: $277.00 <br /> taro.oMey <br /> PtaeranuEigm nt end Reamd Ib Erolayn,o end N ns Daws New Trowivmw AmNeMnrerre <br /> err t)erere <br /> 1028 UCENSED HEALTH CARE FACILITY PR0527280 EE00033131-MARISEL FLOMRSCHUV4uve Y N A 1 D <br /> 2224-HAZ MAT BUSINESS PLAN ALITHORIZATIOIPR061 I M EE0000000-HAZ MAT$JC OES I,tadiw Y N A 1 D <br /> 2Z"-PACT TRANSFER RECORD-OES PRO519M EE00000D0-HAZ MAT SJC OES Active Y N A 1 D <br /> 2=-UNIFIED PRoeRAM FAC STATE SURCHARPRO809105 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> eaau%!G ex!COmP AKe Die .r <br /> 11CIm pan iOdEtW= 1, Merl:Qned awn ,aperO,por a ped Of eon►e,ea�eawteaee Mat eM .andrer pglaat epeaaa Pr�B+EHD f�oury tllsryq eeeoalaed wqh e1e <br /> ♦✓coaly a<aolNlyiMM se Need to Iha parry datMMed as the 01MdER an the,arm. I rase gfMttr tat all ep1r411ene wlM De pnAarmed to ooconaanee wMA eM spptleems O�dkea Cedes endror 6lendersta and <br /> Sete W&W Federal Laws. <br /> f <br /> �AP��.IGINI'SSIlaP1A- _ --6A1t L±/ -941 - <br /> Mogan Records to be TRANSFERED! #920.000 Amount Paid Date- 1 <br /> Water System to bs TRANSFEREO; '$372.00 s Amount Paid Date I ! <br /> Payment Type Check Number Received by - <br /> REEKS: Date !�f Account out: Date <br /> COMMENTS: <br /> «Pi'►s-ehs41-ntlappelenY�iEilta�rsPorts1S021.rpt <br />