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Date run f 11/10/2011 4:02:23P SAN JC ' -"UIN COUNTY ENVIRONMENTAL HE DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 11/10/ <br />Record Selection Criteria: Facility ID FA0003978 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0012830 <br />Owner Name <br />KAISER FOUNDATION HOSPITAL <br />Owner DBA <br />1777 W YOSEMITE AVE <br />Owner Address <br />1777 W YOSEMITE AVE <br />Phone <br />MANTECA, CA 95337 <br />Home Phone <br />209-825-3773 <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />1777 W YOSEMITE AVE <br />Location Code <br />MANTECA, CA 95337 <br />Care of <br />EVS <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0003978 <br />Facility Name <br />KAISER FOUNDATION - MANTECA <br />Location <br />1777 W YOSEMITE AVE <br />Account ID AR0003603 <br />MANTECA, CA 95337 <br />Phone <br />209-825-3773 <br />Mailing Address <br />1777 W YOSEMITE AVE <br />Mail Invoices to Facility <br />MANTECA, CA 95337 <br />Care of <br />ATTN: LEONARD POKLAY-EVS <br />Location Code <br />04 - MANTECA <br />Bos District <br />003 - BESTOLARIDES <br />APN <br />20018034 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name ALVERAZ, DEANNA <br />Title EVS SECRETARY <br />Day Phone 209-825-3773 <br />Night Phone <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0003603 <br />New Account ID: <br />Mail Invoices to Facility <br />Mail Invoices to: Owner / <br />Facility <br />/ <br />Account <br />Account Name KAISER FOUNDATION - MANTECA <br />(Circle One) <br />Account Balance as of 11/10/2011: $0.00 <br />(Circle One) <br />Transfer to <br />Active/inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status <br />New Owner? <br />Delete <br />1628 - LICENSED HEALTH CARE FACILITY PR0527313 <br />EE0003474 - CHANDRA OM Active <br />Y <br />N <br />A <br />I D <br />2220 - SM HW GEN <5 TONS/YR PR0514053 <br />EE0002670 - MUNIAPPA NAIDU Active <br />Y <br />N <br />A <br />I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512118 <br />EE0000000 - HAZ MAT SJC OES Inactive <br />Y <br />N <br />A <br />I D <br />2244 - PACT TRANSFER RECORD - OES PR0519899 <br />EE0000000 - HAZ MAT SJC OES Active <br />Y <br />N <br />A <br />I D <br />2301 - UST STATE SURCHARGE FEE PRO508364 <br />EE0007289 - ALISON YOUNGBLOOD Inactive <br />Y <br />N <br />A <br />I D <br />2361 - UST FACILITY PR0232397 <br />EE0002670 - MUNIAPPA NAIDU Active <br />Y <br />N <br />A <br />I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0507557 <br />EE0007289 - ALISON YOUNGBLOOD Inactive <br />Y <br />N <br />A <br />I D <br />4522 - ACUTE CARE FACILITY PR0450109 <br />EE0003973 - ROBERT MCCLELLON Active <br />Y <br />N <br />A <br />I D <br />4557 - MED WASTE LIMITED HAULER PR0535381 <br />EE0003973 - ROBERT MCCLELLON Active <br />Y <br />N <br />A <br />I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPR0531611 <br />Active <br />Y <br />N <br />A <br />I D <br />'1331 7kV5,3Zr7o?-a, <br />\\eh-env\envision\reports\5021. rpt <br />