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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 4/27/2017 <br />Submitted on: 3/13/2017 12:43:32AM <br />Submitted by: Steve Onsurez Email: steveo@dammfinepizza.com <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 />Number of Facilities for this Owner : 1 <br />OW0021893 <br />Martha Olmos <br />PO Box 449 <br />Bandon, OR 97411-0449 <br />559-920-5418 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0023593 <br />Facility name <br />BLAZE PIZZA (LODI) <br />Site address <br />1537 S LOWER SACRAMENTO RD <br />City <br />LODI <br />ZIP code <br />95242 <br />Facility phone <br />209-369-1169 <br />Facility mailing address 1537 S. Lower Sacramento Road <br />Lodi, CA 95242 <br />BILLING INFORMATION <br />Contact name <br />Address <br />Contact phone <br />Contact email <br />Mail invoices to <br />BLAZE PIZZA <br />PO Box 449 <br />Bandon, OR 97411-0449 <br />541-347-4150 <br />julie@dammfinepizza.com <br />Account <br />CERS ID: 10726207 <br />Facility ID in CERS: FA0023593 <br />Information after CIW processing CERS <br />(current submittal) field <br />Martha Olmos <br />111 <br />PO Box 449 <br />113 <br />Bandon, OR 97411-0449 <br />114, 115, 116 <br />559-920-5418 <br />112 <br />Blaze Pizza ( Lodi ) 3 <br />1537 S Lower Sacramento Rd 103 <br />Lodi 104 <br />95242 �1� 105 <br />209-369-1169 a'Iy 102 <br />1537 S. Lower Sacramen 108a <br />Lodi, CA 95242 ,i 108b, 108c, 108d <br />Julie Stefan l f �I �lo (�`' Lo <br />0 <br />PO Box 449 �� 1 'b 143 <br />Bandon 97411-0449 Q t, 144, 145, 146 <br />541- -4150 1 S y 141 <br />le@dammfinepizza.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 calendar year [ ] next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by <br />Date: <br />Accounting: Reviewed by: Date: 2 I Clerical: [ ] File [ ] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified By: Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Record ID Employee name Status Reactivated Inactivated <br />1625 - RESTAURANT/BAR 51-100 SEATS PR0541194 STEPHANIE RAMIREZ Active [ ] [ ] <br />1919 - HMBP-0O2 Only Food Facility 1 chem units PRO541509 STEPHANIE RAMIREZ Active [ ] [ ] <br />