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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Changes to EnvisionConnect by CERS Integration Wizard Date run: 3/16/2015 Submitted on: 1/19/2015 10:38:44AM CERS ID: 10449784 Submitted by: Dori Longworth Email: dlongworth@westerndental.com Facility ID in CERS: FA0022161 Information prior to CIW processing Information after CIW processing CERS OWNER INFORMATION (current EC database) (current submittal) field Owner ID OW0018242 Owner name Western Dental Services, Inc. Western Dental Services, Inc. 111 Mailing address 530 S. Main Street 530 S. Main Street 113 Orange, CA 92868 Orange, CA 92868 114, 115, 116 Work phone 714-480-3000 714-480-3000 112 FACILITY FILE INFORMATION Facility ID FA0022161 Facility name Western Dental Western Dental 3 Site address 1407 W March Ln 1407 W March Ln 103 City Stockton Stockton 104 ZIP code 95207 95207 105 Facility phone 209-473-4000 209-473-4000 102 Facility mailing address 530 S. Main Street 530 S. Main Street 108a Orange, CA 92868 Orange, CA 92868 108b, 108c,108d BILLING INFORMATION Contact name WESTERN DENTAL SERVICES INC Linda Cueva 140 Address 530 S. Main Street 530 S. Main Street 143 Orange, CA 92868 Orange, CA 92868 144, 145, 146 Contact phone 714-571-3574 714-571-3574 141 Contact email Icueva@westerndental.com Icueva@westerndental.com 142 Mail invoices to Account Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: Assigned to: Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendarear y [ ] exempt from billing Processed through CERS Integration Wizard by: Date: ------------------ Accounting: Reviewed by: Lb Date: 3llg II!�' Clerical: [ j File [ ] Relabel file [ ] Create new file [ ] Acct billed [ ] Surcharge verified g ——_ y: Date: ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW Program Element and Description Record ID Employee name Status Reactivated Inactivated 1921 -HMBP-Regular-Primary Location PR0539214 ROBERT LOPEZ Active [ ] [ ] 2220-SM HW GEN<5 TONSNR PRO538344 FATINAH ZAREEF Active [ ] [ ]