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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 1/21/2015 <br /> Submitted on: 1/7/2015 4:46:53PM CERS ID: 10182389 <br /> Submitted by: Elizabeth Pacheco Email: elizabethp@stjudecarecenter.com Facility ID in CERS: FA0009069 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0007069 <br /> Owner name PALM HAVEN CARE CENTER LLC Jospeh Pallivathucal 111 <br /> Mailing address 469 E NORTH ST 3141 Elyse Ct 113 <br /> MANTECA, CA 95336 Modesto, CA 95355 114, 115, 116 <br /> Work phone 209-823-1788 (209)823-1788 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009069 <br /> Facility name ST JUDE CARE CENTER ST JUDE CARE CENTER 3 <br /> Site address 469 E NORTH ST 469 E NORTH ST 103 <br /> City MANTECA MANTECA 104 <br /> ZIP code 95336 95336 105 <br /> Facility phone 209-823-1788 2098231788 102 <br /> Facility mailing address 469 E NORTH ST 469 E NORTH ST 108a <br /> MANTECA, CA 95336 MANTECA, CA 95336 108b,108c,load <br /> BILLING INFORMATION <br /> Contact name ST JUDE CARE CENTER Patti Romo 140 <br /> Address 469 E NORTH ST 469 E NORTH ST 143 <br /> MANTECA, CA 95336 MANTECA, CA 95336 144, 145, 146 <br /> Contact phone 209-823-1788 / (209)823-1788 141 <br /> Contact email ✓ 142 <br /> Mail invoices to F.a�jlit� <br /> Program record [ ] HMBPP [ ] 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 /> hi <br /> Processed through CERS Integration Wizard by: ;rte) Date: <br /> Accounting: Reviewed by: 7� Date: f/ Clerical: [ ] File [ ] Relabel file [ ] 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 /> 1628-LICENSED HEALTH CARE FACILITY PR0527307 LISA MEDINA Active [ ] [ ] <br /> 1921 -HMBP-Regular-Primary Location PRO519360 MICHAEL PARISSI Active [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0509069 HAZ MAT SJC DES Inactive [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0534607 not assigned Inactive [ ] [ ] <br />