Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 3/20/2015 <br /> Submitted on: 1/27/2015 12:48:10PM CERS ID: 10184507 <br /> Submitted by: Sharon Edmondson Email: sharon.edmondson@davita.com Facility ID in CERS: FA0013665 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0010774 <br /> Owner name DVA Healthcare Renal Care, Inc. DVA Healthcare Renal Care, Inc. 111 <br /> Mailing address 2000 16th St 2000 16th Street 113 <br /> Denver, CO 80202 Denver, CO 80202 114, 115, 116 <br /> Work phone 303-405-2100 303-405-2100 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013665 <br /> Facility name DAVITA MANTECA DIALYSIS CENTER DAVITA MANTECA DIALYSIS CENTER 3 <br /> Site address 1156 S MAIN ST 1156 S MAIN ST 103 <br /> City MANTECA MANTECA 104 <br /> ZIP code 95336 95336 105 <br /> Facility phone 209-823-3078 2098233078 102 <br /> Facility mailing address 5200 VIRGINIA WAY 1156 S MAIN ST 108a <br /> BRENTWOOD, TN 37027 MANTECA, CA 95337 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name Sharon Edmondson Sharon Edmondson 140 <br /> Address 5200 VIRGINIA WAY, L&C Dept 5200 Virginia Way 143 <br /> BRENTWOOD, TN 37027 Brentwood, TN 37027 144, 145, 146 <br /> Contact phone 615-341-6789 615-3241-6789 141 <br /> Contact email sharon.edmondson@davita.com Sharon.edmondson@davita.com 142 <br /> Mail invoices to Facility <br /> Program record [ ] HMBP [ ] SQG HW [ ] LOG HW [ ] RCRA HW New PR#: <br /> created [ j Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: <br /> Assigned to: <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year [ j next calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: �5or Date: <br /> Accounting: Reviewed by: 1/1�? Date: 3�y0 / Clerical: [ ] FileRelabel file <br /> [ ] [ ] Create new file <br /> [ ] Acct billed [ ] Surcharge verified By: Date: <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 PRO521008 MICHAEL PARISSI Active [ ] [ ] <br /> 4530-LG QUANITY GENERATOR PRO522691 ROBERT MCCLELLON Active [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0518046 HAZ MAT SJC DES Inactive [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0534743 not assigned Inactive [ ] [ ] <br />