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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT f <br /> Changes to EnvisionConnect by CERS Integration Wizard Date run: 6/26/2014 <br /> Submitted on: 1/20/2014 5:34:30PM CERS ID: 10183177 <br /> Submitted by: Glen Ganotis Email: gleng@jiffylubeca.com Facility ID in CERS: FA0010067 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0008973 Nim— <br /> Owner name FOWLER, DON W 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 209-339-0795 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,load <br /> BILLING INFORMATION <br /> Contact name JIFFY LUBE#2497 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 209-952-1662 916 375 1155 141 <br /> Contact email gleng@jiffylubeca.com 142 <br /> Mail invoices to Facility <br /> Program record [ ] HMBP [ ] SQG HW [ I 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: Date: <br /> -------------------------------------------- <br /> Accounting: Reviewed by: _Date:11919 I K Clerical: VFiIe [Relabel file [ ] Create new file <br /> [ ] AcqjA511ed [ ] Surc rTe verified By: Date_ <br /> ----- -- -----y ——————————————————— — —— <br /> - <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 HAZA SAEED Active [ ] I 1 <br /> 2228-GEN 25<50 TONS PERMIT PRO514152 Fatina Zareef Active [ 1 [ 1 <br /> 2332-EXEMPT TANK FACILITY PR0528061 Fatina Zareef Inactive [ ] I ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0510067 HAZ MAT SJC OES Inactive [ ] [ 1 <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO537864 Fatina Zareef Active,Exempt [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE F PR0531485 not assigned Inactive [ ] [ 1 <br />