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SAN JOAQUINWOUNTY ENVIRONMENTAL HEALTH -,APARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 8/12/2015 <br />Submitted on: 8/3/2015 8:00:31AM CERS ID: 10636885 <br />Submitted by: Allan Santa Catalina Email: 425@buffalowildwings.com Facility ID in CERS: incorrect <br />OWNER INFORMATION <br />Owner ID <br />Owner name <br />Mailing address <br />Work phone <br />Information prior to CIW processing <br />(current EC database) <br />OW0016958 <br />BLAZIN WINGS INC <br />5500 WAYZATA BLVD STE 1600 <br />MINNEAPOLIS, MN 55416 <br />952-516-8072 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0015179 <br />Facility name <br />BUFFALO WILD WINGS #425 <br />Site address <br />2790 NAGLEE RD <br />City <br />TRACY <br />ZIP code <br />95304 <br />Facility phone <br />952-516-8072 <br />Facility mailing address 5500 WAYZATA BLVD STE 1600 <br />Information after CIW processing CERS <br />(current submittal) field <br />Buffalo Wild Wings 111 <br />2796 Naglee Rd 113 <br />Tracy, CA 95304 114, 115, 116 <br />209-83-3819 112 <br />BUFFALO WILD WINGS <br />MINNEAPOLIS, MN 55416 <br />BILLING INFORMATION <br />103 <br />Contact name <br />BUFFALO WILD WINGS #425 <br />Address <br />5500 WAYZATA BLVD STE 1600 <br />209-833-8319 <br />MINNEAPOLIS, MN 55416 <br />Contact phone <br />Not Specified <br />Contact email <br />Mail invoices to <br />Facility <br />Information after CIW processing CERS <br />(current submittal) field <br />Buffalo Wild Wings 111 <br />2796 Naglee Rd 113 <br />Tracy, CA 95304 114, 115, 116 <br />209-83-3819 112 <br />BUFFALO WILD WINGS <br />3 <br />2796 Naglee Rd <br />103 <br />Tracy <br />104 <br />95304 <br />105 <br />209-833-8319 <br />102 <br />2796 Naglee Rd 108a <br />Tracy, CA 95304 108b, 108c, 108d <br />Buffalo Wild Wings 140 <br />2796 Naglee Rd 143 <br />Tracy, CA 95304 144, 145, 146 <br />209-833-3819 141 <br />425@buffalowildwings.com 142 <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW <br />created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST <br />New PR#: _ <br />New PE: <br />Assigned to: <br />Please bill: [ ] full calendar year [ ] prorate this <br />--calendar year [ ] next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by. Ute"' Date: <br />------------------ <br />I�/- - - <br />Accounting: Reviewed by: Date: g�l 3 I Clerical: [ ] File/ Relabel file [ ] Create new file <br />r Q��# billed r , Ci irr horno vorifl d -By: Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Program Element and Description Record ID Employee name Status Reactivated Inactivated <br />1626 - RESTAURANT/BAR 101 + SEATS PR0522285 MELISSA NISSIM Active [ ] [ ] <br />1921 - HMBP-Regular-Primary Location PR0540230 PETER LOMBARDI Active [ ] [ ] <br />SiTF �fl(LC�S <br />C�-C' <br />N-r�c-lam �Dr c.� �-'1 W�3 S � `� - <br />