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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 2/10l2015 <br /> Submitted on: 1/13/2015 9:54:15AM CERS ID: 10182191 <br /> Submitted by: Sunny Sun Email: ssun@formurex.com Facility ID in CERS: FA0007098 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0005831 <br /> Owner name ZHANG, DONGXIAO (TONY) JASTI, BHASKARA 111 <br /> Mailing address 595 Dalewood Dr 3513 Gleneagles Dr 113 <br /> ORINDA, CA 94563 Stockton, CA 95219 114, 115, 116 <br /> Work phone 510-206-4667 209-581-4102 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007098 <br /> Facility name FORMUREX INC FORMUREX INC 3 <br /> Site address 2470 N WILCOX RD 2470 N WILCOX RD 103 <br /> City STOCKTON STOCKTON 104 <br /> ZIP code 95215 95215 105 <br /> Facility phone 209-931-2040 (209) 931-2040 102 <br /> Facility mailing address 2470 N WILCOX RD 2470 N WILCOX RD 108a <br /> STOCKTON, CA 95215 STOCKTON, CA 95215 108b,1o8c,load <br /> BILLING INFORMATION <br /> Contact name FORMUREX INC FORMUREX INC 140 <br /> Address 2470 N WILCOX RD āœ“ 2470 N WILCOX RD 143 <br /> STOCKTON, CA 95215 STOCKTON, CA 95215 144, 145, 146 <br /> Contact phone 209-931-2040 (209)931-2040 141 <br /> Contact email āœ“ 142 <br /> Mail invoices to i ity <br /> Program record [ J 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: 0}m Date: Iā€”I0 ā€” (rJ <br /> Accounting: Reviewed by: _24,--L Date: 3 ! 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 /> 1921 -HMBP-Regular-Primary Location PR0520003 HAZ MAT SJC OES Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONS/YR PRO514120 JEFFREY WONG Active [ ] [ ] <br /> 2227-GEN 5<25 TONS PERMIT PRO505944 FATINAH ZAREEF Inactive [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PRO509984 HAZ MAT SJC OES Inactive [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PRO534768 not assigned Inactive [ ] [ ] <br />