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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard Date run: 6/21/2014 <br />Submitted on: 3/7/2014 8:52:39AM CERS ID: 10181391 <br />Submitted by: lonnie powders Email: lonnie.powders@dignityhealth.org Facility ID in CERS: FA0003761 <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 />OW0018545 <br />DIGNITY HEALTH FRMLY CHCW <br />PO BOX 213008 <br />STOCKTON, CA 95213-9008 <br />209-943-2000 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0003761 <br />Facility name <br />ST JOSEPHS MEDICAL CENTER <br />Site address <br />1800 N CALIFORNIA ST <br />City <br />STOCKTON <br />Zip code <br />95204 <br />Facility phone <br />209-943-2000 <br />Facility mailing address <br />3400 DATA DR <br />RANCHO CORDOVA, CA 95670 <br />BILLING INFORMATION <br />Contact name ST JOSEPHS MEDICAL CENTER <br />Address 3400 DATA DR <br />RANCHO CORDOVA, CA 95670 <br />Contact phone Not Specified <br />Contact email <br />Mail invoices to Facility <br />Information after CIW processing CERS <br />(current submittal) field <br />DIGNITY HEALTH FORMERLY CATHOLIC <br />111 <br />P.O. BOX 213008 <br />113 <br />STOCKTON, CA 95213-9008 <br />114, 115, 116 <br />(209)943-2000 <br />112 <br />ST JOSEPHS HOSPITAL <br />3 <br />1800 N CALIFORNIA ST <br />103 <br />STOCKTON <br />104 <br />95204 <br />105 <br />(209) 943-2000 <br />102 <br />P.O. BOX 913008 <br />108a <br />STOCKTON, CA 95213 108b, 1080, 1084 <br />CATHY GRAHAM <br />140 <br />3400 DATA DR <br />143 <br />RANCHO CORDOVA, CA 95670 <br />144, 145, 146 <br />1-916-851-2150 <br />141 <br />cathy.graham@dignityhealth.org <br />142 <br />Program record (] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW <br />created [ ] Tiered permit [ ] APSA [ ] CaIARP [ ] UST <br />New PR#: _ <br />New PE: _ <br />Assigned to: <br />Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] calendar year [ <br />] exempt from billing <br />/1next <br />Processed through CERS Integration Wizard by: �XA_ Date: <br />-------------------------------------------------- <br />Accounting: Reviewed by: Date: Etfied Clerical: �] File [ ]Relabel <br />file [ ]Create new file <br />{—Acct billed {—].Surchargev By: <br />Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Program Element and Description Record ID Employee name Status <br />Reactivated Inactivated <br />1626-RESTAURANT/BAR 101+SEATS PRO160504 STEPHANIE RAMIREZ Active <br />[ ] [ ] <br />1921 - HMBP-Regular-Primary Location PRO519820 ROBERT LOPEZ Active <br />2217 -APPLIANCE RECYCLER PR0536119 Fatina Zareef Active, Exempt <br />[ ] [ ] <br />2227 8-1 PRO1,3841 0 Fmfd, 7area; Inactive <br />[ ] [ ] <br />-224-7- RCRA GEN 5<25 TONS 227-1 PRO514003 Fatina Zareef Active <br />[ ] [ ] <br />2301 - UST STATE SURCHARGE FEE PRO515549 LETITIA BRIGGS Inactive <br />[ ] [ ] <br />2361 - UST FACILITY PR0231036 Fatina Zareef Active <br />[ ] [ ] <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0507445 LETITIA BRIGGS Inactive <br />[ ] [ ] <br />2832 -AST FAC 10 K - </=100 K GAL CUMULATIVE PR0528692 GARRETT BACKUS Active <br />[ ] [ ] <br />2951-UGT-CAP PROW 0361 MICHAEL INFURNA Inactive <br />[ ] [ ] <br />4522 - ACUTE CARE FACILITY PRO450006 ALFONSO ARAMBULA Active <br />[ ] [ ] <br />4557 - MED WASTE LIMITED HAULER PR0522306 ROBERT MCCLELLON Active <br />[ ] [ ] <br />