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Date run 6/7/2003 4:38:43PM SAN JOAC `�E <br /> � N COUNTY ENVIRONMENTAL HEALT. � PARTMENT <br /> Report#5021 <br /> Pagel <br /> Run by g Facility Information as of 5/7/2003 <br /> Record Selection Criteria: Facility ID FA0012722 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009452 New Owner ID <br /> Owner Name COMMUNITY MEDICAL CENTERS INC <br /> Owner DBA <br /> Owner Address 701 E CHANNEL ST <br /> STOCKTON, CA 95202 <br /> Home Phone 209-940-7206 <br /> Work/Business Phone Not Specified <br /> Mailing Address 701 E CHANNEL ST <br /> STOCKTON, CA 95202 <br /> Care of VIRGINIA VALDEZ <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012722 <br /> Facility Name LAWRENCE ELEMENTARY HEALTHY STA <br /> Location 721 CALAV ERAS ST <br /> LODI, CA 95240 <br /> Phone 209-368-2212 <br /> Mailing Address 701 E CHANNEL ST 77 <br /> STOCKTON, CA 95202 <br /> Care of COMMUNITY MEDICAL CENTER <br /> Location Code 02 - LODI APN: <br /> BOS District 004- SEIGLOCK, JACK SIC Cade: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID p9 New Account ID: <br /> Mail Invoices Owner <br /> Mail Invoices to: Owner / Facility / Account <br /> Account Name MMUNITY MEDICAL CENTERS INC (Circle One) <br /> Account Balance as of 5!712003: $0.00 <br /> (Circle One) <br /> Transfer to Activennactve <br /> Program/Element and Description Record ID Employee to and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PRO516633 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,andfor project specific,PHSIEHO hourly charges associated with this <br /> facility 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 Ordinate Codes andfor Standards and <br /> State andtor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: '$155.00 Amount Paid Date ! 1 <br /> Payment Type Check Number Received by <br /> RENS: Date 1 ! Account out: _�/4J Date 6 407 /-05 <br /> COMMENTS: <br /> 11Phs-ehsq I-ntlapps\EnvisionslReports15021.rpt <br />