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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 2/9/2017 <br /> Submitted on: 2/8/2017 4:27:OOPM CERS ID: 10181307 <br /> Submitted by: Hussian Ismail Email: alinawazismail12345@gmail.com Facility ID in CERS: FA0003685 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Number of Facilities for this Owner: 1 <br /> Owner ID OW0006644 <br /> Owner name KULJIT MANGAT Hussian Ismail 111 <br /> Mailing address 419 S MAIN ST 419 S MAIN ST 113 <br /> MANTECA, CA 95337 MANTECA, CA 95337 114, 115, 116 <br /> Work phone 209-239-7978 209-276-7013 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003685 <br /> Facility name CIRCLEK/EXPRESS MARKET DBA CIRCLEK, REFUEL PETROLEUM INC. 3 <br /> Site address 419 S MAIN ST 419 S MAIN ST 103 <br /> City MANTECA MANTECA 104 <br /> ZIP code 95336 95336 105 <br /> Facility phone 209-239-7978 (409) 293-5953 <br /> 102 <br /> Facility mailing address 419 S MAIN ST 419 S MAIN ST 108a <br /> MANTECA, CA 95337 MANTECA, CA 95337 108b,108c,1084 <br /> BILLING INFORMATION <br /> Contact name KULJIT MANGAT Hussian Ismail 140 <br /> Address 419 S MAIN ST 419 S MAIN ST 143 <br /> MANTECA, CA 95337 MANTECA, CA 95337 144, 145, 146 <br /> Contact phone 209-239-7978 209-276-7013 141 <br /> Contact email expressmarket@comcast.net alinawazismail12345@gmail.com 142 <br /> Mail invoices to Account <br /> Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA <br /> [ ] CaIARP [ ] 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: L 01 ]� <br /> Accounting: Reviewed by: (1 2, Date: '))W)I Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> [ ] Acct billed [ ] Surcharge verified By: Date: <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Record ID Employee name Status Reactivated Inactivated <br /> 1921 -HMBP-Regular-Primary Location 5 chem units PR0519895 NICHOLAS LOEHRER Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONS/YR PR0519033 ELENA MANZO Active [ ] [ ] <br /> 2361 -UST FACILITY PR0231433 ELENA MANZO Active [ ] [ ] <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512112 HAZ MAT SJC DES Inactive [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PRO507401 ELENA MANZO Inactive [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0534550 not assigned Inactive [ ] [ ] <br />