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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: 4/6/2017 7:52:12AM <br />Submitted by: Phillip Gibson Email: pgibson@chipotle.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 <br />OW0012304 <br />Chipotle Mexican Grill, Inc. <br />1401 Wynkoop St., Suite 500 <br />Denver, CO 80202 <br />303-222-2524 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0023789 <br />Facility name <br />CHIPOTLE MEXICAN GRILL #2865 <br />Site address <br />2512 NAGLEE RD STE 100 <br />City <br />TRACY <br />ZIP code <br />95304 <br />Facility phone <br />303-222-2524 <br />Facility mailing address 1401 WYNKOOP ST STE 500 <br />DENVER, CO 80202 <br />BILLING INFORMATION <br />Contact name CHIPOTLE MEXICAN GRILL #2865 <br />Address 1401 WYNKOOP ST STE 500 <br />DENVER, CO 80202 <br />Contact phone 303-222-2524 <br />Contact email <br />Mail invoices to Facility <br />CERS ID: 10731391 <br />Facility ID in CERS: incorrect <br />Information after CIW processing CERS <br />(current submittal) field <br />Chipotle Mexican Grill, Inc 111 <br />licensing@chipotle.com 113 <br />Denver, CO 80202 114, 115, 116 <br />(303) 222-2524 112 <br />Chipotle Mexican Grill #2865 3 <br />2512 Naglee Rd Ste 100 103 <br />Tracy 104 <br />95304 105 <br />(303) 595-4000 102 <br />1401 Wynkoop St, Suite 500 108a <br />Denver, CO 80202 108b, 10ac, 10sd <br />Licensing 140 <br />1401 Wynkoop St, Suite 500 143 <br />Denver, CO 80202 144, 145, 146 <br />(303) 222-2524 141 <br />licensing@chipotle.com 142 <br />Program record [ ] HMBP [ ] SOG HW [ ] LOG 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: Date: <br />Accounting: Reviewed by: W Date: 512 r i Clerical: [ ] File [ ] Relabel file (] Create new file <br />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 PR0541494 MELISSA NISSIM Active [ ] [ ] <br />1919 - HMBP-0O2 Only Food Facility 1 chem units PR0541495 MELISSA NISSIM Active [ ] [ ] <br />