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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 1/26/2016 <br /> Submitted on: 1/25/2016 3:18:41 PM CERS ID: 10450729 <br /> Submitted by: Denise Pogue Email kpogue@artelllc.net Facility ID in CERS: FA0000388 <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 I D OW0000319 <br /> Owner name Lodi Surgical Associates Lodi Surgical Associates 111 <br /> Mailing address 521 S Ham Lane Suite F 521 S Ham Lane Suite F 113 <br /> Lodi, CA 95242 Lodi, CA 95242 114, 115, 116 <br /> Work phone 209-333-0905 209-333-0905 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000388 <br /> Facility name Lodi Outpatient Surgical Center Lodi Outpatient Surgical Center 3 <br /> Site address 521 S HAM LN STE F 521 S Ham Ln Ste F 103 <br /> City Lodi Lodi 104 <br /> ZIP code 95242 95242 105 <br /> Facility phone 209-333-0905 209-333-0905 102 <br /> Facility mailing address 521 S Ham Lane 521 S Ham Lane 108a <br /> Lodi, CA 95242 Lodi, CA 95242 108b, 108c 108d <br /> BILLING INFORMATION' <br /> Contact name Kippy Pogue Kippy Pogue 140 <br /> Address 521 S Ham Lane 521 S Ham Lane 143 <br /> Lodi, CA 95242 Lodi, CA 95242 144, 145, 146 <br /> Contact phone 209-333-0905 209-333-0905 141 <br /> Contact email kpogue@artelllc.net kpogue@artelllc.net 142 <br /> Mail invoices to Account <br /> Program record [ ] HMBP SQG HW [ ] LQG HW [ ] RCRA HWNew PR#: 'o`13 <br /> created [ ] Tier@d permit ( ] APSA [ ] CalARP [ ] LIST New PE: 2,0 <br /> Assigned to: 1�jL WSJ <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendarear <br /> y [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: Date: ' [ <br /> ------- -------- <br /> Accounting: Reviewed by: e Date: Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> 1 e. <br /> ( ] Acct billed [ ] Surcharge verified By: Date: <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1921 -HMBP-Regular-Primary Location PR0537862 JAMIE DE LA RASA Active [ ] [ ] <br /> 4520-PRIMARY CARE FACILITY PR0450055 BENJAMIN ESCOTTO Active [ ] ( ] <br />