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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 111912016 <br /> Submitted on: 11/212016 10:17:06AM CERS ID: /0186823 <br /> Submitted by: Trish Haberman Email habermt@sutterhealth.org Facility ID in CERS: FA0018191 <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 : 2 <br /> Owner ID OW0002051 <br /> Owner name SUTTER GOULD MEDICAL FOUNDATION SUTTER GOULD MEDICAL FOUNDATION 111 <br /> Mailing address 600 COFFEE RD 600 COFFEE RD 113 <br /> MODESTO, CA 95355 MODESTO, CA 95355 114, 115, 116 <br /> Work phone 209-524-1211 209-524-1211 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018191 <br /> Facility name SUTTER GOULD SUTTER GOULD 3 <br /> Site address 2505 W HAMMER LN 2505 W HAMMER LN 103 <br /> City STOCKTON STOCKTON 104 <br /> ZIP code 95209-2839 95209-2839 105 <br /> Facility phone 209-524-1211 (209) 524-1211 102 <br /> Facility mailing address 2505 W HAMMER LN 2505 W HAMMER LN 108a <br /> STOCKTON, CA 952.09 STOCKTON, CA 95209 108b, 108c.1©8d <br /> BILLING INFORMATION <br /> Contact name SUTTER GOULD MEDICAL FOUNDATION SUTTER GOULD MEDICAL FOUNDATION 140 <br /> Address 600 COFFEE RD 600 COFFEE RD 143 <br /> MODESTO, CA 95355 MODESTO, CA 95355 144, 145, 146 <br /> Contact phone 209-524-1211 209-524-1211 141 <br /> Contact email 142. <br /> Mail invoices to Account <br /> Program record [ ] HMBP [ f SQG HW [ ] LQG HW [ ] RCRA HW New PR#: O S `f t ``t D <br /> created [ ] Tiered permit [ ] APSA [ ] CaIARP [ ] UST New PE: <br /> Assigned to: VV L(_A41- N) "] <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year next calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: Date: <br /> Accounting: Reviewed by: Date: �_1. 10/14- Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> ] Acct billed [ ] Surcharge verified By: Date: <br /> - -- - - - - -- - - - - - <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 PR0530858 JAMIE LIMA Active [ ] [ ] <br /> 4520-PRIMARY CARE FACILITY PRO526860 ROBERT MCCLELLON Active [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0532829 not assigned Inactive [ ] [ ] <br />