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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: 1/19/2015 10:38:44AM <br />Submitted by: Dori Longworth Email: dlongworth@westerndental.com CERS ID: 10449784 <br />Facility ID in CERS: FA0022161 <br />OWNER INFORMATION <br />Owner ID <br />Owner name <br />Mailing address <br />Work phone <br />Information prior to CIW processing <br />(current EC database) <br />OW0018242 <br />Western Dental Services, Inc. <br />530 S. Main Street <br />Orange, CA 92868 <br />714-480-3000 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0022161 <br />Facility name <br />Western Dental <br />Site address <br />1407 W March Ln <br />City <br />Stockton <br />ZIP code <br />95207 <br />Facility phone <br />209-473-4000 <br />Facility mailing address <br />530 S. Main Street <br />Orange, CA 92868 <br />BILLING INFORMATION <br />Contact name <br />WESTERN DENTAL SERVICES INC <br />Address <br />530 S. Main Street <br />Orange, CA 92868 <br />Contact phone <br />714-571-3574 <br />Contact email <br />Icueva@westerndental.com <br />Mail invoices to <br />Account <br />Information after CIW processing CERS <br />(current submittal) field <br />Western Dental Services, Inc. 111 <br />530 S. Main Street 113 <br />Orange, CA 92868 114, 115, 116 <br />714-480-3000 112 <br />Western Dental <br />3 <br />1407 W March Ln <br />103 <br />Stockton <br />104 <br />95207 <br />105 <br />209-473-4000 <br />102 <br />530 S. Main Street <br />108a <br />Orange, CA 92868 <br />108b, 108c, 1086 <br />Linda Cueva 140 <br />530 S. Main Street 143 <br />Orange, CA 92868 144, 145, 146 <br />714-571-3574 141 <br />Icueva@westerndental.com 142 <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW <br />created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST <br />New PR#: _ <br />New PE: _ <br />Assigned to: <br />Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by: '3► Date: J 16 -15 <br />-------- <br />-------------------------------------- <br />Accounting: Reviewed by: L46 Date: 3I/4I1 Clerical: [ ] File [ ] Relabel file [ ] Create new file <br />-- _ [ ] Acct billed [ ] Surcharge verified g <br />----_ y: 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 PR0539214 ROBERT LOPEZ Active [ ] [ ] <br />2220 - SM HW GEN <5 TONSNR PRO538344 FATINAH ZAREEF Active [ ] [ ] <br />