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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 6/7/2016 <br />Submitted on: 5/23/2016 9:37:33AM CERS ID: 10138633 <br />Submitted by: Gayle Howdeshell Email: ghowdesh@lincare.com <br />OWNER INFORMATION <br />Owner ID <br />Owner name <br />Mailing address <br />Work phone <br />.Information prior to CIW processing <br />(current EC database) <br />Number of Facilities for this Owner: 1 <br />OW0017418 <br />LINCARE INC. <br />P 0 BOX 9004 ATTN: LICENSING DEPT <br />CLEARWATER, FL 33758 <br />727-530-7700 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0021143 <br />Facility name <br />LINCARE <br />Site address <br />3727 METRO DR STE A <br />City <br />Stockton <br />ZIP code <br />95215 <br />Facility phone <br />209-943-0738 <br />Facility mailing address 3727 Metro Dr Ste A <br />Stockton, CA 95215 <br />BILLING INFORMATION <br />Contact name <br />Address <br />Contact phone <br />Contact email <br />Mail invoices to <br />GAYLE HOWDESHELL <br />P 0 BOX 9004 ATTN: LICENSING DEPT <br />CLEARWATER, FL 33758 <br />727-431-8283 <br />GHOWDESH@LINCARE.COM <br />Account <br />Facility ID in CERS: FA0021143 <br />Information after CIW processing CERS <br />(current submittal) field <br />LINCARE INC. 111 <br />P 0 BOX 9004 ATTN: LICENSING DEPT. 113 <br />CLEARWATER, FL 33758 114, 115, 116 <br />(727) 530-7700 112 <br />LINCARE 3 <br />3727 Metro Dr Ste A % 10 <br />Stockton V 04 <br />95215 --t05— <br />(209) 943-0738 102 <br />3727 Metro Dr Ste 108a <br />Stockton, CA 15 108b, 1o8c, 1o8d <br />GAYLE HOWDESHELL 140 <br />P 0 BOX 9004 ATTN: LICENSING DEPT. 143 <br />CLEARWATER, FL 33758 144, 145, 146 <br />(727) 431-8283 141 <br />GHOWDESH@LINCARE.COM 142 <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW <br />created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST <br />New PR#: _ <br />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: Date: <br />L <br />-------------------------------------------------- <br />Accounting: <br />—------------------------------------- — --- <br />Accounting: Reviewed by: �6 Date: �1lD 1 Clerical: [ ] File [ ] 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 PR0536811 NICHOLAS LOEHRER Active [ ], <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI PR0536834 not assigned Inactive [ ] [ ] <br />FeLc(14 )J f Ade f e y art Ivory e fW,-v C .jr/1.54 <br />