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SAN JOAQUIN _OUNTY ENVIRONMENTAL HEALTH .,,zPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run' 8/7/2015 <br />Submitted on: 6/23/2015 8:56:32AM <br />Submitted by: Constance Moore Email: connie.moore@ecm-inc.org <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 />OW0016313 <br />SWH MIMI'S CAFE, LLC <br />12201 MERIT DR STE 900 <br />DALLAS, TX 75251 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0019887 <br />Facility name <br />MIMIS CAFE #151 <br />Site address <br />5607 PACIFIC AVE <br />City <br />STOCKTON <br />ZIP code <br />95207 <br />Facility phone <br />209-952-1150 <br />Facility mailing address 12201 MERIT DR STE 900 <br />CERS ID: 10187407 <br />Facility ID in CERS: FA0019887 <br />Information after CIW processing CERS <br />(current submittal) field <br />Mimi's Cafe LLC 111 <br />18872 MacArthur Blvd. 113 <br />Irvine, CA 92612 114, 115, 116 <br />(714) 873-7959 112 <br />MIMIS CAFE #151 3 <br />5607 PACIFIC AVE 103 <br />STOCKTON 104 <br />95207 105 <br />(209) 952-1150 102 <br />5607 Pacific Ave. 108a <br />Stockton, CA 95207 1 o8b, 1 o8c, 1 o8d <br />Steve Yackel 140 <br />18872 MacArthur Blvd. 143 <br />Irvine, CA 92612 144, 145, 146 <br />(951) 240-8982 141 <br />syackel@mimiscafe.com 142 <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 />Please bill: [ ] full calendar year [ ] prorate this calendar year [ J next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by: UA Date: g `1.1 <br />-------------------------------------------------- <br />Accounting: Reviewed by: C6 Date: 01 15 Clerical: [ ] File [ ] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified By: Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Program Element and Description Record ID Employee name Status Reactivated Inactivated <br />1626 - RESTAURANT/BAR 101 + SEATS PR0530657 VIDAL PEDRAZA Active [ ] [ ] <br />1921 - HMP -Regular -Primary Location PR0531242 HAZA SAEED Active [ ] [ ] <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI PR0531728 not assigned Inactive [ ] [ ] <br />DALLAS, TX 75251 <br />BILLING INFORMATION <br />Contact name <br />MIMIS CAFE #151 <br />Address <br />12201 MERIT DR STE 900 <br />DALLAS, TX 75251 <br />Contact phone <br />Not Specified <br />Contact email <br />Mail invoices to <br />Facility <br />CERS ID: 10187407 <br />Facility ID in CERS: FA0019887 <br />Information after CIW processing CERS <br />(current submittal) field <br />Mimi's Cafe LLC 111 <br />18872 MacArthur Blvd. 113 <br />Irvine, CA 92612 114, 115, 116 <br />(714) 873-7959 112 <br />MIMIS CAFE #151 3 <br />5607 PACIFIC AVE 103 <br />STOCKTON 104 <br />95207 105 <br />(209) 952-1150 102 <br />5607 Pacific Ave. 108a <br />Stockton, CA 95207 1 o8b, 1 o8c, 1 o8d <br />Steve Yackel 140 <br />18872 MacArthur Blvd. 143 <br />Irvine, CA 92612 144, 145, 146 <br />(951) 240-8982 141 <br />syackel@mimiscafe.com 142 <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 />Please bill: [ ] full calendar year [ ] prorate this calendar year [ J next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by: UA Date: g `1.1 <br />-------------------------------------------------- <br />Accounting: Reviewed by: C6 Date: 01 15 Clerical: [ ] File [ ] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified By: Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Program Element and Description Record ID Employee name Status Reactivated Inactivated <br />1626 - RESTAURANT/BAR 101 + SEATS PR0530657 VIDAL PEDRAZA Active [ ] [ ] <br />1921 - HMP -Regular -Primary Location PR0531242 HAZA SAEED Active [ ] [ ] <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI PR0531728 not assigned Inactive [ ] [ ] <br />