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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 3/29/2017 <br />Submitted on: 3/21/2017 4:48:20PM <br />Submitted by: Glenda Kierstead Email: glenda@belshire.com <br />OWNER INFORMATION <br />Owner ID <br />Owner name <br />Mailing address <br />Work phone <br />Information prior to CIW processing <br />(current EC database) <br />Number of Facilities for this Owner : 12 <br />OW0000721 <br />7 -ELEVEN INC <br />PO BOX 711 <br />DALLAS, TX 75221 <br />800-828-0711 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0002064 <br />Facility name <br />7 -ELEVEN INC. STORE #14117 <br />Site address <br />2725 COUNTRY CLUB BLVD <br />City <br />Stockton <br />ZIP code <br />95204 <br />Facility phone <br />209-463-1259 <br />Facility mailing address <br />3200 HACKBERRY ROAD <br />2301 - UST STATE SURCHARGE FEE PR0508311 MICHAEL KITH <br />IRVING, TX 75063 <br />BILLING INFORMATION <br />Inactive [ ] [ ] <br />Contact name <br />7 -ELEVEN INC. STORE #14117 <br />Address <br />3200 HACKBERRY ROAD <br />IRVING, TX 75063 <br />Contact phone <br />Not Specified <br />Contact email <br />Mail invoices to <br />Account <br />CERS ID: 10165779 <br />Facility ID in CERS: FA0002064 <br />Information after CIW processing CERS <br />(current submittal) field <br />7 -ELEVEN INC. 111 <br />LICENSE RENEWAL DEPT.:3200 HACKBER 113 <br />IRVING, TX 75063 114, 115, 116 <br />972-828-7578 112 <br />7 -ELEVEN INC. STORE #14117 3 <br />2725 COUNTRY CLUB BLVD 103 <br />Stockton 104 <br />95204 105 <br />209-463-1259 102 <br />LICENSE RENEWAL DEPT.:3200 HACKBER 108a <br />IRVING, TX 75063 108b, 108c, 108d <br />7 -ELEVEN INC. ATTN: BRENT SMERCZYNS 140 <br />LICENSE RENEWAL DEPT.:3200 HACKBER 143 <br />IRVING, TX 75063 144, 145, 146 <br />972-828-7578 141 <br />BRENT.SMERCZYNSKI@7-11.COM 142 <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW <br />created [ ] Tiered permit [ ] APSA [ ] CaIARP [ ] UST <br />New PR#: _ <br />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: <br />1,6v - <br />Date. -),�. -17 <br />Accounting: Reviewed by: Date: � /I1 /11 Clerical: [ ] <br />File [ ] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified <br />By: Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING <br />THROUGH CIW <br />Record ID Employee name <br />Status Reactivated Inactivated <br />1919 - HMBP-0O2 Only Food Facility 1 chem units PR0519761 MARIBEL FLOHRSCHUTZ <br />Active [ ] [ ] <br />2220 - SM HW GEN <5 TONS/YR PRO518490 STACY RIVERA <br />Inactive [ ] [ ] <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511889 HAZ MAT SJC OES <br />Inactive [ ] [ ] <br />2301 - UST STATE SURCHARGE FEE PR0508311 MICHAEL KITH <br />Inactive [ ] [ ] <br />2361 - UST FACILITY PR0231073 STACY RIVERA <br />Inactive [ ] [ ] <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0507291 MICHAEL KITH <br />Inactive [ ] [ ] <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI PR0533925 not assigned <br />Inactive [ ] [ ] <br />