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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 11/14/2014 <br /> Submitted on: 11/3/2014 9:22:11AM 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, 116 <br /> Work phone 560-404-6500 560-404-6500 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 916-437-5800 <br /> 102 <br /> Facility mailing address 300 SANTANA ROW#300 590 E. March In. 108a <br /> SAN JOSE, CA 95128 Stockton, CA 95204 108b, 108c,108d <br /> BILLING INFORMATION <br /> Contact name Satellite Dialysis University Park 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 Not Specified 650-404-6500 141 <br /> Contact email ��tt 142 <br /> Mail invoices to Facylty Pi-/ <br /> Program record [ ] HMBP// [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA [ ] CaIARP [ ] UST New PE: <br /> Assigned to: <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendarear <br /> y [ ] exempt from billing <br /> Processed through CERS Integration Wizard by:y T Date: <br /> Accounting: Reviewed by:_a Date: I[ 11-111!+ Clerical: ?< File [ ] Relabel file [ ] Create new file <br /> --- [ ] Acc I led [ ] Surchar y <br /> ri ied — B : Date: <br /> ------- — ———— ————----- — <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 PRO538332 ROBERT LOPEZ Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONSNR PR0538331 JEFFREY WONG Active [ ] [ ] <br /> 4530-LG QUANITY GENERATOR PR0537144 BENJAMIN ESCOTTO Active [ ] [ ] <br />