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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 9/28/2015 <br /> Submitted on: 9/24/2015 2:25:16PM CERS ID: 10183177 <br /> Submitted by: Glen Ganotis Email: gleng@jiffylubeca.com Facility ID in CERS: FAD010067 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0008973 <br /> Owner name BROADBSE INC. BROADBASE INC. 111 <br /> Mailing address 1471 SHORE ST 1471 SHORE ST 113 <br /> WEST SACRAMENTO, CA 95691 WEST SACRAMENTO, CA 95691 114, 115, 116 <br /> Work phone 916-375-1155 916-375-1155 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010067 <br /> Facility name JIFFY LUBE#2497 JIFFY LUBE#2497 3 <br /> Site address 4715 N WEST LN 4715 N WEST LN 103 <br /> City STOCKTON STOCKTON 104 <br /> ZIP code 95210 95210 105 <br /> Facility phone 209-952-1662 (209)952-1662 102 <br /> Facility mailing address 1471 SHORE ST 1471 SHORE ST 108a <br /> WEST SACRAMENTO, CA 95691 WEST SACRAMENTO, CA 95691 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name Braodbase Inc. Braodbase Inc. 140 <br /> Address 1471 SHORE ST 1471 SHORE ST 143 <br /> WEST SACRAMENTO, CA 95691 WEST SACRAMENTO, CA 95691 144, 145, 146 . <br /> Contact phone 916-375-1155 916 375 1155 141 <br /> Contact email gleng@jiffylubeca.com gleng@jiffylubeca.com 142 <br /> Mail invoices to Facility <br /> Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created ] Tiered permit [ ] APSA [ ] CalARP [ ] 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: W" Date: q Y'K'I4 <br /> ---------------------- ----- <br /> Accounting: Reviewed by:t— Date: q&q/15 Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> [ ] Acct billed [ ] Surcharge-yBLlied�— J---_By: — Date_— <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1921 -HMBP-Regular-Primary Location PR0521063 HAZASAEED Active [ ] [ ] <br /> 2228-GEN 25<50 TONS PERMIT PR0514152 FATINAH ZAREEF Active [ ] [ ] <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0537864 FATINAH ZAREEF Active [ ] [ ] <br /> 2332-EXEMPT TANK FACILITY PR0528061 FATINAH ZAREEF Inactive [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PRO510067 HAZ MAT SJC DES Inactive [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PRO531485 not assigned Inactive [ ] [ I <br />