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SAN JOAQUhVCOUNTY ENVIRONMENTAL HEALTHVtPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 6/27/2014 <br /> Submitted on: 1/24/2014 6:27:15AM CERS ID: 10184615 <br /> Submitted by: Stephanie Fleischer Email: sfleischer@3ecompany.com Facility ID in CERS: FA0014350 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0016236 ( a) <br /> Owner name Longs Drug Stores California, L.L.C. Longs Drug Stores California, L.L.C. 111 <br /> Mailing address 1 CVS Drive 1 CVS Drive 113 <br /> Woonsocket, RI 02895 Woonsocket, RI 02895 114, 115, 116 <br /> Work phone 401-765-1500 (401) 765-1500 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014350 <br /> Facility name CVS/PHARMACY#3908 CVS Pharmacy#3908 3 <br /> Site address 1885 W ELEVENTH ST 1885 W 11th St 103 <br /> City TRACY Tracy 104 <br /> Zip code 95376 95376 105 <br /> Facility phone 209-836-2300 (209) 836-1460 102 <br /> Facility mailing address ONE CVS DR MAIL DROP 23062A CVS Caremarrk�Atttn: Dianne E. Dur nd, 1 C 108a <br /> V MRrt, -D'" a3D(iZA- <br /> WOONSOCKET, RI 02895 Woonsocket, RI 02895 108b,108c,load <br /> BILLING INFORMATION Pd4l) M59-5 <br /> Contact name CVS/PHARMACY#3908 CVS Caremark, Attn: Dianne E. Durand 140 <br /> Address ONE CVS DR MAIL DROP 23062A 1 CVS Drive-23062A 143 <br /> WOONSOCKET, RI 02895 Woonsocket, RI 02895 144, 145, 146 <br /> Contact phone 209-836-2300 (401) 770-3315 141 <br /> Contact email Dianne.Durand@CVSCaremark.com 142 <br /> Mail invoices to Facility <br /> Program record HMBP ( ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: 0 S- <br /> created [ ] Tiered permit ( ] APSA [ ] CalARP [ ] UST New PE: 1412, ( <br /> Assigned to: M e4 r) b!j <br /> Please bill: �Q full calendar year ( ] prorate this calendar year [ ] next calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: U(i- Date: IbIbO <br /> --------------- <br /> Accounting: Revie d by: Date: W;�Fbb q Clerical: [ ] File [ ] Relabel file K Create new file <br /> [ Acct billed By: Date: <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1615-RETAIL MKT 301-2000 SO FT(PREPKGD/LTD PREP; PR0519192 MELISSA NISSIM Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONS/YR PR0522840 MICHELLE HENRY Active [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0532724 not assigned Inactive [ ] [ ] <br /> /v 4,*w- <br /> l'r 29fD <br />