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SAN JOAdWeCOUNTY ENVIRONMENTAL HEALTIr6EPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run' <br /> Submitted on: 5/1/2014 12:30:28PM CERS ID: 10186823 <br /> Submitted by: James Marquez Email: marquezj@sutterhealth.org Facility ID in CERS: FA0018191 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0002051 <br /> Owner name SUTTER GOULD SUTTER GOULD MEDICAL FOUNDATION 111 <br /> Mailing address 2505 W MARCH LN 600 COFFEE RD 113 <br /> STOCKTON, CA 952092839 MODESTO, CA 95355 114, 115, 116 <br /> Work phone 209-524-1211 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018191 <br /> Facility name SUTTER GOULD SUTTER GOULD 3 <br /> Site address 2505 W HAMMER LN 2505 W HAMMER LN 103 <br /> City STOCKTON STOCKTON 104 <br /> Zip code 952092839 95209-2839 105 <br /> Facility phone 209-521-6097 (209) 524-1211 102 <br /> Facility mailing address PO BOX 619110 2505 W HAMMER LN 108a <br /> ROSEVILLE, CA 95661 STOCKTON, CA 95209 108b,1060,load <br /> BILLING INFORMATION <br /> Contact name SUTTER GOULD SUTTER GOULD MEDICAL FOUNDATION ' 140 <br /> Address PO BOX 619110 600 COFFEE RD 143 <br /> ROSEVILLE, CA 95661 MODESTO, CA 95355 144, 145, 146 <br /> Contact phone Not Spe 'tied 209-524-1211 141 <br /> Contact email 142 <br /> Mail invoices to F ility <br /> Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: <br /> Assigned to: <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: Date: <br /> Accounting: Reviewed by: Date:l� Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> [ ] � __ [ ] Surc a veri led_ —___ _By:___ Date: <br /> A filled <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1921 -HMBP-Regular-Primary Location PRO530858 HAZA SAEED Active [ ] [ ] <br /> 4520-PRIMARY CARE FACILITY PR0526860 ROBERT MCCLELLON Active [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE F PRO532829 not assigned Inactive [ ] [ ] <br />