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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard Date run: 6/28/2014 <br /> Submitted on: 1/24/2014 6:29:58AM CERS ID: 10184937 <br /> Submitted by: Stephanie Fleischer Email: sfleischer@3ecompany.com Facility ID in CERS: FA0015387 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0016236 <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) 770-3315 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015387 <br /> Facility name CVS/PHARMACY#9830 CVS Pharmacy#9830 3 <br /> Site address 6632 PACIFIC AVE 6632 Pacific Ave 103 <br /> City STOCKTON Stockton 104 <br /> Zip code 95207 95207 105 <br /> Facility phone 401-770-3315 (209) 951-6544 102 <br /> Facility mailing address ONE CVS DR LICENSING DEPT MAIL DR CVS Caremark, Attn: Dianne E. Durand, 1 C 108a <br /> WOONSOCKET, RI 02895 Woonsocket, RI 02895 108b,108c,108d <br /> BILLING INFORMATION ''C1` v-2� <br /> Contact name CVS/PHARMACY#9830 CVS Caremark, Attn: Dianne E. Durand 140 <br /> Address ONE CVS DR LICENSING DEPT MAIL DR 1 CVS Drive-23062A 143 <br /> WOONSOCKET, RI 02895 Woonsocket, RI 02895 144, 145, 146 <br /> Contact phone 401-770-3315 (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#: <br /> created Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: 4f 2 <br /> Assigned to: R'LA P11 <br /> Please bill: full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: R()fi- Date: Z -1 <br /> ------------------------------------------------- - <br /> Accounting: <br /> --------- --------- <br /> Accounting: Reviewed by: Date: / Clerical: [ ] File [ ] Relabel file ]Create new file <br /> [ cctbilled ( _— —_ _— -- — —_--- Date: <br /> —_ <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1618-RETAIL MKT>2000 SQ FT (PREPKGD/LTD PREP) PR0522583 MARIBEL FLOHRSCHUTZ Active [ ] [ 1 <br /> 2220-SM HW GEN<5 TONS/YR PR0536194 MICHELLE HENRY Active [ ] [ 1 <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PRO536195 MICHELLE HENRY Inactive [ ] I 1 <br /> l b ojv_,011� " <br />