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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 2/17/2016 <br />Submitted on: 1/27/2016 2:42:46PM <br />Submitted by: Mark House Email: mhouse@freebirds.com <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 />OW0017206 <br />TAVISTOCK FREEBIRDS LLC <br />6475 CHRISTIE AVE STE 300 <br />EMERYVILLE, CA 94608 <br />FACILITY FILE INFORMATION <br />CERS ID: 10646014 <br />Facility ID in CERS: FA0006869 <br />Information after CIW processing CERS <br />(current submittal) field <br />Tavistock Freebirds, LLC. 111 <br />9050 N. Capital of Texas Hwy. suite 360 113 <br />Austin, TX 78759 114, 115, 116 <br />512-428-6202 112 <br />Facility ID <br />FA0006869 <br />Facility name <br />FREEBIRDS WORLD BURRITO <br />Freebirds - 20719 Tracy <br />3 <br />Site address <br />1920 W ELEVENTH ST <br />1920 W 11th St <br />103 <br />City <br />TRACY <br />Tracy <br />104 <br />ZIP code <br />95376 <br />95376 <br />105 <br />Facility phone <br />209-835-6000 <br />512-428-6202 <br />102 <br />Facility mailing address 2295 S HIAWASSEE RD STE 402 <br />ORLANDO, FL 32835 <br />BILLING INFORMATION <br />Contact name FREEBIRDS WORLD BURRITO <br />Address 2295 S HIAWASSEE RD STE 402 <br />ORLANDO, FL 32835 <br />Contact phone Not Specified <br />Contact email <br />Mail invoices to Facility <br />9050 N. Capital of Texas Highway ste. 36( 108a <br />Austin, TX 78759 108b, 108c, 108d <br />Mark House 140 <br />9050 N. Capital of Texas Hwy. suite 360 143 <br />Austin, TX 78759 144, 145, 146 <br />512-428-6202 141 <br />mhouse@freebirds.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 />',�lthis calendar year [ ] next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by: 'W'_ Date: a 'I� - <<,-, <br />------------y-------------------------- ---------- <br />Accounting.Reviewed by: Date: 2b Clerical: [ ] File [ ] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified By: Date: <br />-------------------------------------------------- <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Program Element and Description Record ID Employee name Status Reactivated Inactivated <br />1625 - RESTAURANT/BAR 51-100 SEATS PR0505575 MELISSA NISSIM Active I I I I <br />-1921 - HMBP-Regular-Primary Location PR0540353 PETER LOMBARDI Active I I I I <br />