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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 4/27/2017 <br />Submitted on: 4/13/2017 3:13:53PM <br />Submitted by: Chris Raymond Email: raymondc@eorm.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 />OW0021373 <br />EL POLLO LOCO INC <br />3535 HARBOR BLVD STE 100 <br />COSTA MESA, CA 92626 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0023225 <br />Facility name <br />EL POLLO LOCO #6128 <br />Site address <br />2442 NAGLEE RD <br />City <br />TRACY <br />ZIP code <br />95304 <br />Facility phone <br />714-599-5000 <br />Facility mailing address 3535 HARBOR BLVD STE 100 <br />COSTA MESA, CA 92626 <br />BILLING INFORMATION <br />Contact name EL POLLO LOCO INC <br />Address 3535 HARBOR BLVD STE 100 <br />COSTA MESA, CA 92626 <br />Contact phone 714-599-5000 <br />Contact email <br />Mail invoices to Facility <br />CERS ID: 10728646 <br />Facility ID in CERS: incorrect <br />Information after CIW processing CERS <br />(current submittal) field <br />EI Polio Loco 111 <br />3535 Harbor Boulevard, Suite 100 113 <br />Costa Mesa, CA 92626 114, 115, 116 <br />(714)599-5045 112 <br />EI Polio Loco Store # 6128 <br />2442 Naglee Rd <br />Tracy <br />95304 <br />209)839-8592 <br />EIPolio oco 28 2-Y 4.2 <br />Trac A 04 <br />Dan Milojevich <br />3535 Harbor Boulevard, Suite 100 <br />Costa Mesa, CA 92626 <br />(714)599-5045 <br />dmilojevich@elpolloloco.com <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW <br />created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST <br />New PR#: <br />New PE: <br />Assigned to: <br />3 <br />103 <br />104 <br />105 <br />102 <br />108b, 108c, 108d <br />140 <br />143 <br />144, 145, 146 <br />141 <br />142 <br />Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by. ��`" Date: <br />Accounting: Reviewed by: Date: 2� / Clerical: [ ] File (] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified By: Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Record ID Employee name Status Reactivated Inactivated <br />1625 - RESTAURANT/BAR 51-100 SEATS PR0540607 MELISSA NISSIM Active I ] I ] <br />1919 - HMBP-0O2 Only Food Facility 1 chem units PR0541647 MELISSA NISSIM Active I ] I ] <br />