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A116 AdhL <br /> SAN JOAQUINIOUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard Date run: 7/11/2014 <br /> Submitted on: 3/13/2014 6:36:49AM CERS ID: 10449784 <br /> Submitted by: Dori Longworth Email: dlongworth@westerndental.com Facility ID in CERS: FA0022161 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0018242 <br /> Owner name Western Dental Services, Inc. Western Dental Services, Inc. 111 <br /> Mailing address 530 S. Main Street 530 S. Main Street 113 <br /> Orange, CA 92868 Orange, CA 92868 114, 115, 116 <br /> Work phone 714-480-3000 714-480-3000 112 <br /> FACILITY FILE INFORMATION 1!/ <br /> Facility ID FA0022161 1V <br /> Facility name Western Dental Western Dental 3 <br /> Site address 1407 W March Ln 1407 W March Ln 103 <br /> City Stockton Stockton 104 <br /> Zip code 95207 95207 105 <br /> Facility phone 209-473-4000 209-473-4000 102 <br /> Facility mailing address 530 S. Main Street 530 S. Main Street 108a <br /> Orange, CA 92868 Orange, CA 92868 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name Linda Cueva Linda Cueva 140 <br /> Address 530 S. Main Street 530 S. Main Street 143 <br /> Orange, CA 92868 Orange, CA 92868 144, 145, 146 <br /> Contact phone 714-571-3574 714-571-3574 141 <br /> Contact email Icueva@westerndental.com Icueva@westerndental.com 142 <br /> Mail invoices to Facility <br /> Program record -�4 HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: <br /> Assigned to: <br /> Please bill: [Q full calendar year [ ] prorate this calendar yearnext calendar year [ ] exempl from billing <br /> Processed through CERS Integration Wizard by: - 1 <br /> _Date: ` 1�� <br /> Accounting: Reviewed by: V' Date: _� Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> [ Acct billed [ ] Surcharge verified------------------------------------ <br /> By: Date <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 2220-SM HW GEN<5 TONSNR PRO538344 Fatina Zareef Active I I I I <br />