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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Changes to EnvisionConnect by CERS Integration Wizard Date run 11/21/20161 ouumateu on: i-inui'Z016 1:07:25PM CERS ID: 10181391 Submitted by: john Stagg Email: john.stagg@dignityhealth.org Facility ID in CERS: FA0003761 OWNER INFORMATION Owner ID Owner name Mailing address Work phone mtormatlon prior to CIW processing (current EC database) Number of Facilities for this Owner : 1 OW0018545 PORT CITY OPERATING COMPANY LLC PO BOX 213008 STOCKTON, CA 95213-9008 209-943-2000 FACILITY FILE INFORMATION Facility ID FA0003761 Facility name ST JOSEPHS HOSPITAL Site address 1800 N CALIFORNIA ST City STOCKTON ZIP code 95204 Facility phone 209-943-2000 Facility mailing address P.O. BOX 213008 P.O. BOX 213008 STOCKTON, CA 2139008 BILLING INFORMATION 114, 115,116 Contact name CATHY GRAHAM Address 3400 DATA DR P.O. BOX 213008 RANCHO CORDOVA, CA 95670 Contact phone 191-685-1215 Contact email cathy.graham@dignityhealth.org Mail invoices to Account Information after CIW processing CERS (current submittal) field Port City LLC DBA St. Joseph's Medical 111 P.O. BOX 213008 113 STOCKTON, CA 95213-9008 114, 115,116 (209) 943-2000 112 ST JOSEPHS HOSPITAL 3 1800 N CALIFORNIA ST 103 STOCKTON 104 95204 105 (209) 943-2000 102 P.O. BOX 213008 108a STOCKTON, CA 2139008 10eb. i58c. 10ad CATHY GRAHAM 140 3400 DATA DR 143 RANCHO CORDOVA, CA 95670 144, 145. 146 1-916-851-2150 141 cathy.graham@dignityhealth.org 142 Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW created [ ] Tiered permit [ ] APSA [ j CalARP [ ] UST New PR#: _ New PE: _ Assigned to: Please bill: [ I full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from billing Processed through CERS Integration Wizard by: � Date: I I ): Y �',, Accounting: Reviewed by: t4& Date: [ III30/1 (v Clerical: [ ] File [ ] Relabel file [ ] Create new file [ ] Acct billed [ ] Surcharge verified — —----------------------------------- By: Date: ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW Program Element and Description Record ID Employee name Status Reactivated Inactivated 1626 - RESTAURANT/BAR 101 + SEATS PRO160504 JEFFREY WONG Active [ ] [ ] 1921 - HMBP-Regular-Primary Location PR0519820 HAZA SAEED Active [ ] [ ] 2217 -APPLIANCE RECYCLER PR0636119 STACY RIVERA Active [ ] [ ] 2227 - GEN 5<25 TONS PERMIT PR0514003 STACY RIVERA Active [ ] [ ] 2361 - UST FACILITY PRO231036 STACY RIVERA Active [ ] [ ] 2832 - AST FAC 10 K - </=100 K GAL CUMULATIVE PRO528692 STACY RIVERA Active [ ] [ ] 4522 -ACUTE CARE FACILITY PRO450006 BENJAMIN ESCOTTO Active [ ] [ ] 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512004 HAZ MAT SJC DES Inactive 2226 - CaIARP PROGRAM PR0514656 HAZ MAT SJC DES Inactive [ ] [ ] 2301 - UST STATE SURCHARGE FEE PRO515549 LETITIA BRIGGS Inactive [ ] [ ] 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0507445 LETITIA BRIGGS Inactive [ ] [ ] 2951 - UGT-CAP PR0010361 MICHAEL INFURNA Inactive [ ] [ ] 4557 - MED WASTE LIMITED HAULER PR0522306 ROBERT MCCLELLON Inactive [ ] [ ] ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI PRO532552 not assigned Inactive [ ] [ ]