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SAN JOAQUINTFUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 7/2/2014 <br /> Submitted on: 5/31/2013 12:57:14PM CERS ID: 10187229 <br /> Submitted by: Steven Tarkan Email: steven.tarkan@blueshieldca.com Facility ID in CERS: FA0019418 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0015914 <br /> Owner name BLUE SHIELD OF CALIFORNIA BLUE SHIELD OF CALIFORNIA 111 <br /> Mailing address 4203 TOWN CENTER BLVD 3021 Reynolds Ranch Pkwy 113 <br /> ELDORADO HILLS, CA 95672 Lodi, CA 95240 114, 115, 116 <br /> Work phone 209-371-3822 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019418 <br /> Facility name BLUE SHIELD OF CALIFORNIA BLUE SHIELD OF CALIFORNIA 3 <br /> Site address 3021 REYNOLDS RANCH PKWY 3021 REYNOLDS RANCH PKWY 103 <br /> City LODI LODI 104 <br /> Zip code 95240 95240 105 <br /> Facility phone 916-350-7794 209-371-3822 102 <br /> Facility mailing address 10700 PRAIRIE LAKES DR 10700 PRAIRIE LAKES DR 108a <br /> EDEN PRAIRIE, MN 55344 EDEN PRAIRIE, MN 55344 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name BLUE SHIELD/CONCUR INVOICE CAPTUF BLUE SHIELD/CONCUR INVOICE CAPTUF 140 <br /> Address 10700 PRAIRIE LAKES DR 10700 PRAIRIE LAKES DR 143 <br /> EDEN PRAIRIE, MN 55344 EDEN PRAIRIE, MN 55344 144, 145, 146 <br /> Contact phone Not Specified 209-371-3822 141 <br /> Contact email 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 /> Processed through C RS Integration Wizard by: Date: <br /> ------- ----------- -- — -- --- -- --- <br /> Accounting: Reviewed by: 0 — — <br /> Date: C—lerical:—— [——File File [ ] Relabel file—[ ] Create new file- <br /> [ ] Acct [ ] Surchar 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 /> 1626-RESTAURANT/BAR 101 +SEATS PRO629100 STEPHANIE RAMIREZ Active [ ] [ ] <br /> 1921 -HMBP-Regular-Primary Location PR0535625 JAMIE DE LA ROSA Active [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE F PR0536018 not assigned Inactive [ ] [ ] <br />