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E_ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CFRS Integration Wizard <br /> Date run: 6/21/2014 <br /> Submitted on: 4129/2014 11:55:20AM 13 <br /> CERS ID: 104839 <br /> Submitted by: mandeep dua Email: duamandeep@yahoo.com Facility ID in CERS: 018 3 16 <br /> 39 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Owner ID OW0015716 <br /> Owner name DUA, MANDEEP S DUA, MANDEEP S 111 <br /> Mailing address 1755 VENICE CIR 1755 VENICE CIR 113 <br /> STOCKTON, CA 95206 STOCKTON, CA 95206 114, 115, 116 <br /> Work phone 209-239-4475 209-815-5180 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003716 <br /> Facility name SUPER STOP GAS & LIQUOR* SUPER STOP GAS & LIQUOR* 3 <br /> Site address 290 N MAIN ST STE C 290 N MAIN ST STE C 103 <br /> City MANTECA MANTECA 104 <br /> Zip code 95336 95336 105 <br /> Facility phone 209-239-4475 (209) 239-4475 102 <br /> Facility mailing address 290 N MAIN ST STE#C 290 N MAIN ST STE#C 108a <br /> MANTECA. CA 95336 MANTECA, CA 95336 1085, 108c.108d <br /> BILLING INFORMATION <br /> Contact name SUPER STOP GAS & LIQUOR* SUPER STOP GAS & LIQUOR` 140 <br /> Address 290 N MAIN ST STE#C 290 N MAIN ST STE#C 143 <br /> MANTECA, CA 95336 MANTECA, CA 95336 144, 145, 146 <br /> Contact phone 209-451-0924 209-239-4475 141 <br /> Contact email 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: Date: <br /> - — -------- - <br /> Accounting: Reviewed by: Date; Clerical: [ ile [ ] Relabel file [ ] Create new file <br /> [ ] Ac ifled [ ] Surcha d'fieed� By.- Date: <br /> --�A + ---- Y------ <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1920-HMBP-Common Materials PRO521166 MICHAEL PARISSI Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONSIYR PR0518116 ELENA MANZO Active [ ] [ ] <br /> 2301 -UST STATE SURCHARGE FEE PR0508394 ALISON YOUNGBLOOD Inactive [ ] [ ] <br /> 2361 -UST FACILITY PR0231438 ELENA MANZO Active [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PRO507417 ALISON YOUNGBLOOD Inactive [ ] [ ] <br />