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E_ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 1211612016 <br /> Submitted on: 12/1312016 10:56:23AM CERS ID: 10187531 <br /> Submitted by: Gary Bry Email: gbry@uspi.com Facility ID in CERS FA0020112 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Number of Facilities for this Owner : 1 <br /> Owner ID OW0016513 <br /> Owner name AMBULATORY SURGERY CTR OF STKN AMBULATORY SURGERY CTR OF STKN 111 <br /> Mailing address 2388 N CALIFORNIA ST 2388 N CALIFORNIA ST 113 <br /> STOCKTON, CA 95204 STOCKTON, CA 95204 114, 115, 116 <br /> Work phone 209-944-9100 209-944-9100 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0020112 <br /> Facility name AMBULATORY SURGERY CTR OF STOCk AMBULATORY SURGERY CTR OF STOCKT( 3 <br /> Site address 2388 N CALIFORNIA ST 2388 N CALIFORNIA ST 103 <br /> City STOCKTON STOCKTON 104 <br /> ZIP code 95204 95204 105 <br /> Facility phone 209-944-9100 (209) 944-9100 102 <br /> Facility mailing address 2388 N CALIFORNIA ST 2388 N CALIFORNIA ST 108a <br /> STOCKTON.. CA 95204 STOCKTON, CA 95204 108b, 108C 108th <br /> BILLING INFORMATION <br /> Contact name AMBULATORY SURGERY CTR OF STOCI< AMBULATORY SURGERY CTR OF STOCKT( 140 <br /> Address 2388 N CALIFORNIA ST 2388 N CALIFORNIA ST 143 <br /> STOCKTON, CA 95204 STOCKTON, CA 95204 144, 145. 146 <br /> Contact phone 209-944-9100 209-944-9100 141 <br /> Contact email 142 <br /> Mail invoices to Account <br /> Program record [ ] HMBP [xj SQG HW [ ] LQG HW [ ] RCRA HW New PR#: RC)5 ti I's D <br /> created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: 22?o <br /> Assigned to: t V <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year j ] next calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: QtA_v Date: I. 16.10 <br /> Accounting: Reviewed by: Lf,,) Date: 1411 11 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 4 chem units PR0531226 HAZA SAEED Active [ ] [ ] <br /> 4520-PRIMARY CARE FACILITY PR0536158 BENJAMIN ESCOTTO Active [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PRO532101 not assigned Inactive [ ] [ ] <br />