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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 12/22/201 <br />Submitted on: 12/21/2015 2:53:22PM CERS ID: 10184499 <br />Submitted by: Nick Eddy Email: eddy@autochlor.com Facility [Din CERS: FA0013659 <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 />Number of Facilities for this Owner : 1 <br />OW0010768 <br />JERRY IVY <br />450 FERGUSON DR <br />MOUNTAIN VIEW, CA 94043 <br />650-967-3085 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0013659 <br />Facility name <br />AUTO -CHLOR SYSTEM <br />Site address <br />1122 BESSEMER AVE # E <br />City <br />MANTECA <br />ZIP code <br />95336 <br />Facility phone <br />209-823-8495 <br />Facility mailing address <br />1122 Bessemer Ave E <br />Manteca, CA 95336 <br />BILLING INFORMATION <br />Contact name <br />Nick Van Zant <br />Address <br />450 FERGUSON DR <br />MOUNTAIN VIEW, CA 94043 <br />Contact phone <br />650-967-3085 <br />Contact email <br />vanzant@autochlor.com <br />Mail invoices to <br />Account <br />Information after CIW processing CERS <br />(current submittal) field <br />JERRY IVY 111 <br />450 FERGUSON DR 113 <br />MOUNTAIN VIEW, CA 94043 114, 115, 116 <br />650-967-3085 112 <br />AUTO -CHLOR SYSTEM 3 <br />1122 BESSEMER AVE E 103 <br />MANTECA 104 <br />95336 105 <br />(209) 823-8495 102 <br />1122 Bessemer Ave E 108a <br />Manteca, CA 95336 108b, 108c, 108d <br />John Ashton 140 <br />1122 Bessemer Avenue 143 <br />Manteca, CA 95337 144, 145, 146 <br />209-823-8495 141 <br />ashton@autochlor.com 142 <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW <br />created [ ] Tiered permit [ ] APSA [ ] CaIARP [ ] UST <br />New PR#: _ <br />New PE: <br />Assigned to: <br />Please bill: [ ] full calendar year [ ] prorate <br />`,�,this calendar year [ ] next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by: v Date: I' `�_j i" <br />Accounting: Reviewed by: I,) Date: /��Z''�15 Clerical: [ ] File [ ] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified By: 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 PRO521001 NICHOLAS LOEHRER Active [ ] [ ] <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0518030 HAZ MAT SJC OES Inactive [ ] [ ] <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI PR0534380 not assigned Inactive [ ] [ ] <br />