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SAN JOAQUI OUNTY ENVIRONMENTAL HEALT PARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 6/27/2014 <br /> Submitted on: 3/7/2014 2:48:04PM CERS ID: 10184561 <br /> Submitted by: BETH GRUBA Email: bethg@harmans.com Facility ID in CERS: FA0014100 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0011163 <br /> Owner name FROILAN 284 INC AMGMT/SACRAMENTO REGION 111 <br /> Mailing address PO BOX 572530 CHRMAN <br /> 334GERBERRD 113 <br /> SALT LAKE CITY, UT 84517-2530ACRAMENTO, 95828 114, 115, 116 <br /> Work phone 209-931-8994 16-689-2190 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014100 <br /> Facility name KFC/A&W#284 KFC/A&W#284 3 <br /> Site address 4450 E WATERLOO RD 4450 E WATERLOO RD 103 <br /> City STOCKTON STOCKTON 104 <br /> Zip code 952152306 95215-2306 <br /> 105 <br /> Facility phone 209-931-8994 (209) 931-8994 102 <br /> Facility mailing address PO BOX 572530 8334 GERBER RD 108a <br /> SALT LAKE CITY, UT 84517-2530 SACRAMENTO, CA 95828-3710 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name KFC/A&W#284 KFC/A&W#284 140 <br /> Address PO BOX 572530 P.O. BOX 572514 <br /> SALT LAKE CITY, UT 84517-2530 SALT LAKE CI TT UT 84157 144, 145,3 <br /> 146 <br /> Contact phone Not Specified / 801-313-8000 141 <br /> Contact email / ' 4p✓ l 142 <br /> Mail invoices to F /1 <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 this calendar year [ /],,next calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: of 4/Date: 0401 t Ll <br /> --- -- ---- ------ --- --- ------- ------ -- -- - <br /> Accounting. Reviewed by: _PQ Date: �/� Clerical: k File [ ] Relabel file [ ] Create new file <br /> [ ] Ac filled [ ] Surdverified 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 PR0518724 LEYNA HUYNH Active [ ] [ ] <br /> 1921 -HMBP-Regular-Primary Location PRO521250 JAMIE DE LA ROSA Active [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PRO518726 Inactive [ ] [ ] <br /> 3116-STORMWATER INSPECTION-FOOD PR0523053 VIDAL PEDRAZA Inactive [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0531761 not assigned Inactive [ ] [ ] <br />