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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 9/28/2015 <br />Submitted on: 9/24/2015 2:25:16PM <br />Submitted by: Glen Ganotis Email: gleng@jiffylubeca.com <br />CERS ID: 10183177 <br />Facility ]Din CERS: FA0010067 <br />Employee name <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 />OW0008973 <br />ZIP code 95210 <br />95210 <br />Owner name <br />BROADBSE INC. <br />BROADBASE INC. <br />111 <br />Mailing address <br />1471 SHORE ST <br />1471 SHORE ST <br />113 <br />WEST SACRAMENTO, CA 95691 <br />WEST SACRAMENTO, CA 95691 <br />WEST SACRAMENTO, CA 95691 <br />114, 115, 116 <br />Work phone <br />916-375-1155 <br />916-375-1155 <br />112 <br />FACILITY FILE INFORMATION <br />Facility ID FA0010067 <br />Record ID <br />Employee name <br />Facility name JIFFY LUBE #2497 <br />JIFFY LUBE #2497 <br />3 <br />Site address 4715 N WEST LN <br />4715 N WEST LN <br />103 <br />City STOCKTON <br />STOCKTON <br />104 <br />ZIP code 95210 <br />95210 <br />105 <br />Facility phone 209-952-1662 <br />(209) 952-1662 <br />102 <br />Facility mailing address 1471 SHORE ST <br />1471 SHORE ST <br />108a <br />WEST SACRAMENTO, CA 95691 <br />WEST SACRAMENTO, CA 95691 <br />108b, 108c, 108d <br />BILLING INFORMATION <br />PR0531485 <br />not assigned <br />Contact name Braodbase Inc. <br />Braodbase Inc. <br />140 <br />Address 1471 SHORE ST <br />1471 SHORE ST <br />143 <br />WEST SACRAMENTO, CA 95691 <br />WEST SACRAMENTO, CA 95691 <br />144, 145, 146 <br />Contact phone 916-375-1155 <br />916 375 1155 <br />141 <br />Contact email gleng@jiffylubeca.com <br />gleng@jiffylubeca.com <br />142 <br />Mail invoices to Facility <br />Program record [ ] HMBP [ ] SQG HW [ ] LOG HW <br />[ ] RCRA HW New PR#: <br />created [ ] Tiered permit [ ] APSA [ ] CaIARP <br />[ ] UST New PE: <br />Assigned to: <br />Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from billing <br />1 <br />W" <br />' <br />Processed through CERS Integration Wizard by: <br />Date: <br />---------------------- <br />Accounting: Reviewed by: _th Date: a�29%1 ,� <br />Clerical: [ ]File [ ]Relabel file <br />[ ]Create new file <br />[ ] Acct billed [ ] Surchar e <br />By: <br />Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Program Element and Description <br />Record ID <br />Employee name <br />Status Reactivated Inactivated <br />1921 - HMBP-Regular-Primary Location <br />PR0521063 <br />HAZA SAEED <br />Active [ ] [ ] <br />2228 - GEN 25<50 TONS PERMIT <br />PR0514152 <br />FATINAH ZAREEF <br />Active [ ] [ ] <br />2831 -AST FAC >/= 1,320 - <10 K GAL CUMULATIVE <br />PR0537864 <br />FATINAH ZAREEF <br />Active [ ] [ ] <br />2332 - EXEMPT TANK FACILITY <br />PR0528061 <br />FATINAH ZAREEF <br />Inactive [ ] [ ] <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FEE <br />PR0510067 <br />HAZ MAT SJC OES <br />Inactive [ ] [ ] <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI <br />PR0531485 <br />not assigned <br />Inactive [ ] [ ] <br />