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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 6/912017 <br />Submitted on: 6/8/2017 2:58:44PM CERS ID: 10737547 <br />Submitted by: Harry Yu Email: mikasa138@yahoo.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 />Number of Facilities for this Owner <br />OW0015006 <br />YU, HARRY G <br />15971 ROCKY HARBOR RD <br />LATHROP, CA 953308791 <br />209-830-8288 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0018278 <br />Facility name <br />MIKASA JAPANESE BISTRO <br />Site address <br />15138 S HARLAN RD <br />City <br />LATHROP <br />ZIP code <br />95330 <br />Facility phone <br />209-858-1818 <br />Facility mailing address 15138 S HARLAN <br />LATHROP, CA 95330 <br />BILLING INFORMATION <br />Contact name MIKASA JAPANESE BISTRO <br />Address 15138 S HARLAN <br />LATHROP, CA 95330 <br />Contact phone 209-981-9981 <br />Contact email <br />Mail invoices to Facility <br />Information after CIW processing CERS <br />(current submittal) field <br />Mikasa Japanese Bistro <br />111 <br />15138 S Harlan Road <br />113 <br />Lathrop, CA 95330 <br />114, 115, 116 <br />(209)858-1818 <br />112 <br />MIKASA JAPANESE BISTRO <br />3 <br />15138 S Harlan Rd <br />103 <br />Lathrop <br />104 <br />95330 <br />105 <br />(209) 858-1818 <br />102 <br />15138 S Harlan Road <br />108a <br />Lathrop, CA 95330 <br />108b, 108c, 08d <br />Mikasa Japanese Bisto <br />140 <br />15138 S Harlan Road <br />143 <br />Lathrop, CA 95330 <br />144, 145, 146 <br />(209) 858-1818 <br />141 <br />mikasa138@yahoo.com <br />142 <br />Program record [ ] HMBP (] SQG HW [ ] LOG HW [ ] RCRA HW New PR#: _ <br />created [ ] Tiered permit [ ] APSA [ ] CaIARP [ ] UST New PE: _ <br />Assigned to: <br />Please bili: [ ] full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from billing <br />Processed through CERS Integration Wizard by: ,JniVt Date: "- 7 <br />------9.----- --I � ---- — [ ] [ ]----[,--—- <br />Accountin Reviewed by: 1� Date: Clerical: File Relabel file Create new file <br />[ ] Acct billed [ ] Surcharge verified By: Date: <br />-------------------------------------------------- <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Record ID Employee name Status Reactivated Inactivated <br />1625 - RESTAURANT/BAR 51-100 SEATS PR0526980 MELISSA NISSIM Active [ ] [ ] <br />1919 - HMBP-0O2 Only Food Facility 1 chem units PR0541910 MELISSA NISSIM Active [ ] [ ] <br />a.5 per o"W reA'i,14`Tk . Cl,c je o6 410 aMrJVI S� <br />Jed Ley ey(D <br />