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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 1/15/2015 <br /> Submitted on: 1/14/2015 3:32:551PM CERS ID: 10458379 <br /> Submitted by: Terri Grenz Email: grenzt@satellitehealth.com Facility ID in CERS: FA0021322 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0017577 <br /> Owner name Satellite Healthcare Satellite Healthcare 111 <br /> Mailing address 300 Santana Row#300 300 Santana Row#300 113 <br /> San Jose, CA 95128 San Jose, CA 95128 114, 115,116 <br /> Work phone 650-404-6500 650-404-6500 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0021322 <br /> Facility name Satellite Dialysis University Park Satellite Dialysis University Park 3 <br /> Site address 590 E Harding Way 590 E Harding Way 103 <br /> City Stockton Stockton 104 <br /> ZIP code 95204 95204 105 <br /> Facility phone 209-774-5800 209-774-5800 102 <br /> Facility mailing address 590 E Harding Way 590 E. Harding Way 108a <br /> Stockton, CA 95204 Stockton, CA 95204 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name Satellite Dialysis University Park Satellite Healthcare 140 <br /> Address 590 E Harding Way 300 Santana Row#300 143 <br /> Stockton, CA 95204 San Jose, CA 95128 144, 145, 146 <br /> Contact phone Not Specified 650-404-6500 141 <br /> Contact email / 142 <br /> Mail invoices to Account VI <br /> Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA [ ] CalARP ( ] UST New PE: <br /> Assigned to: <br /> Please bill: [ ] full calendar year [ ] prorate this <br /> _calendar year [ ] next calendar year [ ] exempt from billing <br /> ` i Processed through CERS Integration Wizard by: Date: A.1; .14 <br /> --------------------------------------- <br /> -----9. ----- ----- --3 a ---- --- -- - -- --- <br /> Accountin Reviewed by: Zr(- Date: -f //� 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 PR0538332 ROBERT LOPEZ Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONSNR PR0538331 JEFFREY WONG Active [ ] [ ] <br /> 4530-LG QUANITY GENERATOR PRO537144 BENJAMIN ESCOTTO Active [ ] [ ] <br />