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SAN JOAQUIN-COUNTY ENVIRONMENTAL HEALTH I EPARTMENT Changes to EnvisionConnect by CERS Integration Wizard Date run: 9/22/2016 Submitted on: 8/30/2016 11:28:56AM CERS ID: 10187427 Submitted by: Robin Kuehne Email: rkuehne@artelllc.net Facility ID in CERS: FA0019928 Information prior to CIW processing Information after CIW processing CERS OWNER INFORMATION (current EC database) (current submittal) field Number of Facilities for this Owner: 1 Owner ID OW0016351 Owner name ENDOSCOPY CENTER OF LODI LLC ENDOSCOPY CENTER OF LODI LLC 111 Mailing address 840 S FAIRMONT AVE STE#1 840 S FAIRMONTAVE STE#1 113 LODI, CA 95240 LODI, CA 95240 114, 115, 116 Work phone 209-371-8700 209-371-8700 112 FACILITY FILE INFORMATION Facility ID FA0019928 Facility name ENDOSCOPY CENTER OF LODI LLC ENDOSCOPY CENTER OF LODI LLC 3 Site address 840 S FAIRMONT AVE STE 1 840 S FAIRMONT AVE STE 1 103 City LODI LODI 104 ZIP code 95240 95240 105 Facility phone 209-333-0905 (209)333-0905 102 Facility mailing address 840 S FAIRMONTAVE STE#1 840 S FAIRMONTAVE STE#1 108a LODI, CA 95240 LODI, CA 95240 10eb,108c,108d BILLING INFORMATION Contact name ENDOSCOPY CENTER OF LODI LLC ENDOSCOPY CENTER OF LODI LLC 140 Address 840 S FAIRMONTAVE STE#1 840 S FAIRMONTAVE STE#1 143 LODI, CA 95240 LODI, CA 95240 144, 145, 146 Contact phone 209-371-8700 209-371-8700 141 Contact email rkuehne@artelllc.net 142 Mail invoices to Account Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: Assigned to: Please bill: [ ] full calendar year [ ] prorate thisc. ndar year [ ] next calendar year [ ] exempt from billing Processed through CERS Integration Wizard by: Wfi Date: I/Z2�ko --------------------------------------------------- Accounting: Reviewed by: Date: 9� Clerical: [ ] File [ ] Relabel file [ ] Create new file [ ] Acct billed [ ] Surcharge verified By: Date: ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW Program Element and Description Record ID Employee name Status Reactivated Inactivated 1921 -HMBP-Regular-Primary Location PRO530772 JAMIE LIMA Active [ ] 14 4530 -2220-SM HW GEN<5 TONSNR PRO540736 FATINAH ZAREEF Active [ ] J',c 4530-LG QUANITY GENERATOR PR0536153 ALFONSO ARAMBULA Active [ ] [ ] ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PRO532119 not assigned Inactive [ ] [ ] -�MMv44cj WIeA 01 , C" �ubm+ n vviflo � � _� jwIt.l;