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SAN JOAQUIN ,OUNTY ENVIRONMENTAL HEALTH ur-PARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 8/12/2015 <br />Submitted on: 8/5/2015 3:14:08PM <br />Submitted by: Omar Alrahimee Email: cafivestarburger@yahoo.com <br />CERS ID: 10181055 <br />Facility ID in CERS: FA0003077 <br />Information prior to CIW processing <br />Information after CIW processing <br />CERS <br />OWNER INFORMATION <br />(current EC database) <br />(current submittal) <br />field <br />Owner ID <br />OW0014511 <br />Owner name <br />RAHIMEE, OMAR AL <br />Omar Alrahimee <br />111 <br />Mailing address <br />625 BERK AVE APT #7 <br />625 Berk Ave Apt #7 <br />113 <br />RICHMOND, CA 94804 <br />Richmond, CA 94804 <br />114, 115, 116 <br />Work phone <br />510-604-8079 <br />510 604-8039 <br />112 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0003077 <br />Facility name <br />CALIFORNIA FIVE STAR BURGER <br />FIVE STAR BURGER <br />3 <br />Site address <br />400 W ELEVENTH ST <br />400 W ELEVENTH ST <br />103 <br />City <br />TRACY <br />TRACY <br />104 <br />ZIP code <br />95376 <br />95376 <br />105 <br />Facility phone <br />209-835-3308 <br />(209) 836-6032 <br />102 <br />Facility mailing address <br />400 W ELEVENTH ST <br />400 W 11th Street <br />108a <br />TRACY, CA 95376 <br />Tracy, CA 95376 <br />108b, 10ac, 10sd <br />BILLING INFORMATION <br />Contact name <br />CALIFORNIA FIVE STAR BURGER <br />Omar Alrahimee <br />140 <br />Address <br />400 W ELEVENTH ST <br />625 Beck Ave Apt #7 <br />143 <br />TRACY, CA 95376 <br />Richmond, CA 94804 <br />144, 145, 146 <br />Contact phone <br />Not Specified <br />510 604-8039 <br />141 <br />Contact email <br />cafivestarburger@aol.com <br />142 <br />Mail invoices to <br />Facility <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br />created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: <br />Assigned to: <br />Please bill: [ ] full calendar year [ ] prorate <br />,this <br />� (calendar year [ ] next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by: vim" Date: <br />Accounting: Reviewed by: ,i} Date: 50.241 �_ Clerical: �\ File [ ] Relabel file [ ] Create new file <br />--1—ttrettri+IP . 1 Surrha[ge 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 />1624 - RESTAURANT/BAR 21-50 SEATS PRO161421 MELISSA NISSIM Active [ ] [ ] <br />1921 - HMBP-Regular-Primary Location PR0527144 PETER LOMBARD] Active [ ] [ ] <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI PR0534142 not assigned Inactive [ ] [ ] <br />