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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard Date run: 10/28/2016 <br /> Submitted on: 10/27/2016 9:20:16AM CERS ID: 10710919 <br /> Submitted by: Sergio Anaya Email: bigserg78@comcast.net Facility ID in CERS: incorrect <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Number of Facilities for this Owner: 1 <br /> Owner ID OW0022035 <br /> Owner name PINNACLE HOSPITALITY GROUP LLC Pinnacle Hospitality Group, LLC 111 <br /> Mailing address PO BOX 780512 200 Centre on The Lake 113 <br /> WICHITA, KS 67278 Lake St. Louis, MO 63367 114, 115, 116 <br /> Work phone 636-265-0266 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0001764 <br /> Facility name LONG JOHN SILVERS #31911 Long John Silver's 32098 3 <br /> Site address 314 N WILSON WAY 314 N Wilson Way 103 <br /> City STOCKTON Stockton 104 <br /> ZIP code 95205 95205 105 <br /> Facility phone 209-941-0117 209-941-0117 102 <br /> Facility mailing address PO BOX 780512 314 N. Wilson Way 108a <br /> WICHITA, KS 67278 Stockton, CA 95205 108b, 108c,108d <br /> BILLING INFORMATION <br /> Contact name LONG JOHN SILVERS #31911 InfoSync 140 <br /> Address PO BOX 780512 P.O. Box 780512 143 <br /> WICHITA, KS 67278 Wichita, KS 67278 144, 145, 146 <br /> Contact phone 636-206-5007 316-685-1622 141 <br /> Contact email pinnacle.ap@issvc.com 142 <br /> Mail invoices to Facility <br /> Program record [ ] HMBP [ ] SOG HW [ ] LOG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA [ ] CaIARP [ ] 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: �'� r Date: c/� ,/'y <br /> -- - -- - - -- - - - - - ----------- - - - <br /> Accounting: Reviewed by: Date: to I31 II 4 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 /> 1624-RESTAURANT/BAR 21-50 SEATS PRO160465 LEYNA HUYNH Active [ ] [ ] <br /> 1919-HMBP-0O2 Only Food Facility PRO541373 LEYNA HUYNH Active [ ] [ ] <br />