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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard Date run: 12!23/201 <br /> Submitted on: 11/25/2014 3:56:52PM CERS ID: 10458379 <br /> Submitted by: Terri Grenz Email: grenzt@satellitehealth.com Facility ID in CERS: FA0021322 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0017577 <br /> Owner name Satellite Healthcare Satellite Healthcare 111 <br /> Mailing address 300 Santana Row#300 300 Santana Row#300 113 <br /> San Jose, CA 95128 San Jose, CA 95128 114, 115, 115 <br /> Work phone 560-404-6500 650-404-6500 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0021322 <br /> Facility name Satellite Dialysis University Park Satellite Dialysis University Park 3 <br /> Site address 590 E Harding Way 590 E Harding Way 103 <br /> City Stockton Stockton 104 <br /> ZIP code 95204 95204 105 <br /> Facility phone 916-437-5800 209-774-5800 102 <br /> Facility mailing address 590 E. March In. 590 E. Harding Way 108a <br /> Stockton, CA 95204 Stockton, CA 95204 108b, 108c 108d <br /> BILLING INFORMATION <br /> Contact name Satellite Healthcare Satellite Healthcare 140 <br /> Address 300 Santana Row#300 300 Santana Row#300 143 <br /> San Jose, CA 95128 San Jose, CA 95128 144, 145, 146 <br /> Contact phone 650-404-6500 650-404-6500 141 <br /> Contact email 142 <br /> Mail invoices to Account <br /> Program record [ ] HMBP [ ] SQG HW [ ] LOG HW [ ] RCRA HW New PRN: <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: _ AI Date: :-24-L` . <br /> ----------------------------------------- <br /> Accounting: Reviewed by: 0 Date: f 5 5 Clerical: )6File [ ] Relabel file [ ] Create new file <br /> [ ] Acct billed [ ] Surcharge verified By: Date: <br /> -------------------------------------------------- <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 PR0538332 ROBERT LOPEZ Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONS/YR PRO538331 JEFFREY WONG Active [ ] [ ] <br /> 4530-LG QUANITY GENERATOR PRO537144 BENJAMIN ESCOTTO Active [ ] [ ] <br />