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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 11/30/201E <br />Submitted on: 11/21/2016 8:41:48AM <br />Submitted by: Trish Haberman Email: habermt@sutterhealth.org <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 />OW0017606 <br />SUTTER GOULD MEDICAL FOUNDATION <br />600 COFFEE RD <br />MODESTO, CA 95355 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0021375 <br />Facility name <br />SUTTER GOULD MEDICAL FOUNDATION <br />Site address <br />2545 W HAMMER LN <br />City <br />STOCKTON <br />ZIP code <br />95209 <br />Facility phone <br />000-000-0000 <br />Facility mailing address 600 COFFEE RD <br />MODESTO, CA 95355 <br />BILLING INFORMATION <br />Contact name <br />Address <br />Contact phone <br />Contact email <br />Mail invoices to <br />SUTTER GOULD MEDICAL FOUNDATION <br />600 COFFEE RD <br />MODESTO, CA 95355 <br />Not Specified <br />Facey P <br />CERS ID: 10187831 <br />Facility ID in CERS: FA0021375 <br />Information after CIW processing CERS <br />(current submittal) field <br />SUTTER GOULD MEDICAL FOUNDATION <br />600 COFFEE RD <br />MODESTO, CA 95355 <br />2095241211 <br />SUTTER GOULD MEDICAL FOUNDATION <br />2545 W HAMMER LN <br />STOCKTON <br />95209 <br />m)-009=8869 <br />600 COFFEE RD <br />MODESTO, CA 95355 <br />SUTTER GOULD MEDICAL FOUNDATION <br />600 COFFEE RD <br />MODESTO, CA 95355 <br />2095241211 <br />111 <br />113 <br />114, 115, 116 <br />112 <br />3 <br />103 <br />104 <br />105 <br />102 <br />108a <br />108b, 108c. 108d <br />140 <br />143 <br />144, 145, 146 <br />141 <br />142 <br />Program record [ ] HMBP SQG HW [ ] LQG HW [ ] RCRA HW New PR#: 2{��ci ► Ll 0 <br />created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: 22Zo <br />Assigned to: Me- c iOA("In <br />Please bill: [ ] full calendar year [ ] prorate this calendar year Xnext calendar year [ ]'exempt from billing <br />Processed through CERS Integration Wizard by: 1%� Date: l 1 - 2D 1 <br />------------ <br />Accounting: Reviewed by: U2? Date: I 13`0 t i/ Clerical: [ ] File [ ] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified By: Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Record ID Employee name Status Reactivated Inactivated <br />1921 - HMBP-Regular-Primary Location PR0537246 JAMIE LIMA Active i i I I <br />