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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 5/11/2017 <br />Submitted on: 5/2/2017 2:19:42PM CERS ID: 10484962 <br />Submitted by: bindra bindra Email: dolly.bindra@empres.com Facility ID in CERS: FA0018493 <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 />OW0015191 <br />California Aviv LLC <br />303 W Madison St Suite 2400 <br />Chicago, IL 60606 <br />360-892-6628 <br />FACILITY FILE INFORMATION <br />Information after CIW processing CERS <br />(current submittal) field <br />California Aviv LLC 111 <br />303 W Madison St : 113 <br />Chicago, IL 60606 114, 115, 116 <br />360 892 6628 ext 283 112 <br />Facility ID FA0018493 <br />Facility name New Hope Post Acute Care <br />New Hope Post Acute Care <br />3 <br />Site address 2586 Buthmann Ave <br />2586 Buthmann Ave <br />103 <br />City Tracy <br />Tracy <br />104 <br />ZIP code 95376 <br />95376 <br />105 <br />Facility phone 209-832-2273 <br />209 832 2273 <br />102 <br />Facility mailing address 2586 Buthmann Ave <br />2586 Buthmann Ave <br />108a <br />Tracy, Ca 95376 <br />Tracy, CA 95376 <br />108b, 108c, 1084 <br />BILLING INFORMATION <br />Contact name Nancy Lee <br />Nancy Lee <br />140 <br />Address 2586 Buthmann Ave <br />2586 Buthmann Ave <br />143 <br />Tracy, CA 95376 <br />Tracy, CA 95376 <br />144, 145, 146 <br />Contact phone 208-322-273 <br />201832 2273 <br />141 <br />Contact email nlee@empres.com <br />nlee@empres.com <br />142 <br />Mail invoices to Facility <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW <br />[ ] RCRA HW New PR#: <br />created [ ] Tiered permit [ ] APSA [ ] CalARP <br />[ ] UST New PE: <br />Assigned to: <br />Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendar year [ <br />] exempt from billing <br />Processed through CERS Integration Wizard by: 0)"- �;_ <br />Date: <br />Accounting: Reviewed by: L46 Date: ���/ % <br />Clerical: [ ] File [ ] Relabel <br />file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified <br />By: <br />Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO <br />PROCESSING THROUGH CIW <br />Record ID Employee name Status <br />Reactivated Inactivated <br />1628 - LICENSED HEALTH CARE FACILITY PR0527306 MELISSA NISSIM Active <br />[ ] [ ] <br />1921 - HMBP-Regular-Primary Location 2 chem units PR0539292 NICHOLAS LOEHRER Active <br />[ ] [ ] <br />4524 - SKILLED NURSING FACILITY PR0536174 ALFONSO ARAMBULA Inactive <br />[ ] [ ] <br />