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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 3/16/2015 <br /> Submitted on: 1119/2015 10:39:10AM CERS ID: 10449796 <br /> Submitted by: Dori Longworth Email: dlongworth@westerndental.com Facility ID in CERS: FA0022159 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0018238 <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 <br /> Facility ID FA0022159 <br /> Facility name Western Dental Western Dental 3 <br /> Site address 7860 WEST LN STE B5 7860 West Ln Ste B5 103 <br /> City Stockton Stockton 104 <br /> ZIP code 95210 95210 105 <br /> Facility phone 209-954-1727 209-954-1727 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 WESTERN DENTAL SERVICES INC 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 Account <br /> Program record [ ] HMBP [ ] SOG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ j Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: <br /> Assigned to: <br /> Please bill: ( ] full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from 'billing <br /> r <br /> Processed through CERS Integration Wizard by: ! "` Date: [ " <br /> Accounting: Reviewed by: � Date: �/l X11� Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> [ ] Acct billed [ ] Surcharge verified g <br /> y: 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 PR0539216 HAZA SAEED Active I ] t ] <br /> 2220-SM HW GEN<5 TONS/YR PRO538342 FATINAH ZAREEF Active Q ] [ ] <br />