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SAN JOAQUIIV-COUNTY ENVIRONMENTAL HEALTH vrEPARTMENT <br /> Changes to EnvisionConnect by CERS integration Wizard <br /> Date run 6/2(}12014 <br /> Submitted on: 6/3/2014 10:36:18AM CERS ID: 10180893 <br /> Submitted by: Roger Batra Email: roger.batra@quikstop.com Facility IE] in CERS: FA0002232 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0000478 <br /> Owner name QUIK STOP MARKETS INC QUIK STOP MARKETS INC 111 <br /> Mailing address 4567 ENTERPRISE ST 4567 ENTERPRISE ST 113 <br /> FREMONT, CA 94538-7605 FREMONT, CA 94538-7605 114, 115, 116 <br /> Work phone 510-657-8500 510-657-8500 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0002232 <br /> Facility name QUIK STOP MARKET#3132* QUIK STOP MARKET#3132` 3 <br /> Site address 3555 W HAMMER LN 3555 W HAMMER LN 103 <br /> City Stockton STOCKTON 104 <br /> Zip code 95219 95209 105 <br /> Facility phone 209-951-3195 (209) 951-3195 102 <br /> Facility mailing address 4567 ENTERPRISE ST 4567 ENTERPRISE ST 108a <br /> FREMONT, CA 94538-7605 FREMONT, CA 94538-7605 108e, 108G,108d <br /> BILLING INFORMATION <br /> Contact name QUIK STOP MARKET#3132* QUIK STOP MARKET#3132* 140 <br /> Address 4567 ENTERPRISE ST 4567 ENTERPRISE ST 143 <br /> FREMONT, CA 94538-7605 FREMONT, CA 94538-7605 144. 145, 146 <br /> Contact phone 510-445-2285 510-445-2285 141 <br /> Contact email mike.karvelot@quikstop.com roger.batra@quikstop.com 142 <br /> Mail invoices to Facility ./ <br /> Program record [ ] HMBP [ ] SQG HW [ ] LOG 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: v 1" Date: ('W <br /> Accounting: Reviewed by: �Date: Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> Acc Iled <br /> Surch <br /> [ l [ ] erveri le By, Date: <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1617-RETAIL MARKET> 1040 SQ FT W 1 FOOD PREP PR0160303 NICHOLAS WIESEMAN Active [ ] [ ] <br /> 1921 -HMBP-Regular-Primary Location PRO519800 HAZA SAEED Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONSIYR PR0526835 Fatina Zareef Active [ ] [ ] <br /> 2301 -UST STATE SURCHARGE FEE PRO515541 MICHAEL KITH Inactive [ ] [ ] <br /> 2361 -UST FACILITY PR0231130 Fatina Zareef Active [ ] [ ] <br /> 2399-UNIFIED PROGRAMFAC STATE SURCHARGE FEE PRO507297 MICHAEL KITH Inactive [ ] [ ] <br />