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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 11/7/2014 <br /> Submitted on: 10/7/2014 8:39:25AM CERS ID: 10450999 <br /> Submitted by: Dori Longworth Email: dlongworth@westerndental.com <br /> Facility ID in CERS: FA0022158 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0018236 <br /> Owner name Western Dental Services, Inc Western Dental Services, Inc 111 <br /> Mailing address 530 South Main St. 530 South Main St. 113 <br /> Orange, CA 92868 Orange, CA 92868 114, 115. 115 <br /> Work phone 714-480-3000 714-480 -3000 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0022158 <br /> Facility name Western Dental Western Dental 3 <br /> Site address 320 S Cherokee Ln 320 South Cherokee Lane 103 <br /> City Lodi Lodi 104 <br /> ZIP code 95240 95240 105 <br /> Facility phone 209-366-7970 209-366-7970 102 <br /> Facility mailing address 530 South Main St. 530 South Main St. 108a <br /> Orange, CA 92868 Orange, CA 92868 108e, 108c,108d <br /> BILLING INFORMATION <br /> Contact name Linda Cueva Linda Cueva 140 <br /> Address 530 South Main St. 530 South Main St. 143 <br /> Orange, CA 92868 Orange, CA 92868 144, 145, 146 <br /> Contact phone 714-571-3574 714-571-3574 141 <br /> Contact email Icueva@viesterndental.com Icueva@westerndental.com 142 <br /> Mail invoices to 5*'I <br /> Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA [ j CalARP [ ] UST New PE: <br /> Assigned to: <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendar year <br /> � �II y [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: 11A Date: <br /> -------------- <br /> Accounting: Reviewed by: Date: / 2 Clerical: l t, File [ ] Relabel file [ j Create new file <br /> [ ] pctbrlr [ ] Sur -- — nfied--- ---_ /--- By: Date: <br /> -- --Ac ' ed <br /> ------------ <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated In ivaled <br /> 1921 -HMBP-Regular-Primary Location PR0539217 JAMIE DE LA ROSA Active [ ] <br /> 2220-SM HW GEN<5 TONSIYR PRO538341 ARIS VELOSO Active [ ] [ ] <br />