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E- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 6/18/2014 <br /> Submitted on: 5/30/2013 1:16:24PM CERS ID: 10184507 <br /> Submitted by: Sharon Edmondson Email: sharon.edmondson@davita.corr 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 DAVITA INC DVA Healthcare Renal Care, Inc. 111 <br /> Mailing address PO BOX 2037 2000 16th St 113 <br /> TACOMA, WA 984012037 Denver, CO 80202 114, 115, 116 <br /> Work phone 3034052100 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 (209) 823-3078 <br /> 102 <br /> Facility mailing address 5200 VIRGINIA WAY 5200 VIRGINIA WAY 108a <br /> BRENTWOOD, TN 37027 BRENTWOOD, TN 37027 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name DAVITA MANTECA DIALYSIS CENTER Sharon Edmondson 140 <br /> Address 5200 VIRGINIA WAY 5200 VIRGINIA WAY, L&C Dept 143 <br /> BRENTWOOD, TN 37027 BRENTWOOD, TN 37027 144, 145, 146 <br /> Contact phone Not Specified 6153416789 141 <br /> Contact email sharon.edmondson@davita.com 142 <br /> Mail invoices to Facility. <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 /> I" <br /> Processed through CERS Integration Wizard by: ( Date: b <br /> g: y N Clerical: [ ] File Relabel file [ ] Create new file- <br /> Accounting: <br /> "/ — ------- - <br /> Accountin Reviewed b : Date:/d/���7 <br /> ----- [ ] A Illed [ j Surch verified —By:---_ 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 PRO521008 MICHAEL PARISSI Active [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PRO518046 HAZ MAT SJC DES Inactive [ ] [ ] <br /> 4530-LG QUANITY GENERATOR PRO522691 ROBERT MCCLELLON Active [ ] [ ] <br />