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SAN JOAQUIrrCOUNTY ENVIRONMENTAL HEALTh-riEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard Date run: 3/26/2015 <br /> Submitted on: 216!2015 4:39:03PM CERS IO: 10186529 <br /> Submitted by: mary medeiros-collier Email: maryontheranch@gmail.com F=acility ID in CERS: FA0017492 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0014333 <br /> Owner name ELSIE MEDEIROS ELSIE MEDEIROS 111 <br /> Mailing address 20051 N DUSTIN RD 20051 N DUSTIN RQ 113 <br /> ACAMPO, CA 95220 ACAMPO, CA 95220 114, 115, 116 <br /> Work phone 209-334-4092 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017492 <br /> Facility name 'ELSIE MEDEIROS ELSIE MEDEIROS 3 <br /> Site address 20051 N DUSTIN RD 20051 N DUSTIN RD 103 <br /> City ACAMPO ACAMPO 104 <br /> ZIP code 95220 95220 105 <br /> Facility phone 209-334-4092 (209) 334-4092 0 102 <br /> Facility mailing address 20051 N DUSTIN RD 20051 N DUSTIN RD 108a <br /> ACAMPO, CA 95220 ACAMPO, CA 95220 108b, 108c,1084 <br /> BILLING INFORMATION <br /> Contact name ELSIE MEDEIROS ELSIE MEDEIROS 140 <br /> Address 20051 N DUSTIN RD 20051 N DUSTIN RQ 143 <br /> ACAMPO, CA 95220 ACAMPO, CA 95220 144, 14 146 <br /> Contact phone Not Specified 209-334-4092 1411 <br /> Contact email 142 <br /> Mail invoices to Owner <br /> Program record [ ] HMBP [ ] SOG HW [ ] LOC HW [ ] RCRA HW New PR#: <br /> created [ ] 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 /> Processed through CERS Integration Wizard by: y Date: ��('- <br /> Accounting: Reviewed by: Date: 31yu'II Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> [ ] Acct billed [ ] Surcharge verified By: Date: f <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Em to ee name Status Reactivated Inactivated <br /> 1958-HM-Farm Operations PRO525677 JAMIE DE LA ROSA Active [ 1 1 <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0530460 WILLY NG Inactive [ ] [ l <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PRO531608 not assigned Inactive [ ] F <br />