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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 11130!2016 <br /> Submitted on: 1112112016 8:41:48AM CERS ID: 10187831 <br /> Submitted by: Trish Haberman Email: habermta@sutterhealth.org Facility ID in CERS: FA0021375 <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 OW0017606 <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 2095241211 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0021375 <br /> Facility name SUTTER GOULD MEDICAL FOUNDATION SUTTER GOULD MEDICAL FOUNDATION 3 <br /> Site address 2545 W HAMMER LN 2545 W HAMMER LN 103 <br /> City STOCKTON STOCKTON 104 <br /> ZIP code 95209 95209 105 <br /> Facility phone 000-000-0000 000)-00flr=0000 102 <br /> Facility mailing address 600 COFFEE RD 600 COFFEE RD 108a <br /> MODESTO. CA 95355 MODESTO, CA 95355 108b, ioac.108d <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 Not Specified 2095241211 141 <br /> Contact email 142 <br /> Mail invoices to Fac <br /> Program record [ ] HMBP SQG HW [ ] LQG HW [ ] RCRA HW New PR#: �K l W SPI <br /> created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: <br /> Assigned to: 1rn.LCMAr--t:j <br /> Please bill: [ ] full calendar year [ ] prorate this c44alendar year next calendar year [ ]'exempt from billing <br /> Processed through CERS Integration Wizard by. �'N Date: ] ` X70 ) �O <br /> Accounting: Reviewed by: tb Date: 11 3011 1,0 Clerical: [ ] File [ J 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 PRO537246 JAMIE LIMA Active i I [ I <br />