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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 5/12/2017 <br />Submitted on: 5/9/2017 2:27:52PM CERS ID: 10642324 <br />Submitted by: Jill Carlson Email: jcarlson429@gmail.com Facility ID in CERS: FA0018622 <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: 1 <br />OW0000533 <br />Maddox Resources Inc. <br />161 N SECOND AVE <br />Oakdale, CA 95361 <br />209-847-1025 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0018622 <br />Facility name <br />Mountain Mikes Pizza <br />Site address <br />1255 Lillian Ave STE C <br />City <br />Escalon <br />ZIP code <br />95320 <br />Facility phone <br />209-838-8200 <br />Facility mailing address 161 North Second Ave <br />Information after CIW processing CERS <br />(current submittal) field <br />Maddox Resources Inc. 111 <br />161 North Second Avenue 113 <br />Oakdale, CA 95361 114, 115, 116 <br />2098471025 112 <br />Mountain Mikes Pizza 3 <br />1255 Lillian Ave 103 <br />Escalon 104 <br />95320 105 <br />209-838-8200 102 <br />161 North Second Ave 108a <br />Oakdale, CA 95361 108b, 108c, 108d <br />Maddox Resources <br />Oakdale, CA 95361 <br />BILLING INFORMATION <br />143 <br />Contact name <br />Maddox Resources Inc <br />Address <br />161 North Second Ave <br />jcarlson429@gmail.com <br />Oakdale, CA 95361 <br />Contact phone <br />209-847-1025 <br />Contact email <br />jcarlson429@gmail.com <br />Mail invoices to <br />Account <br />Information after CIW processing CERS <br />(current submittal) field <br />Maddox Resources Inc. 111 <br />161 North Second Avenue 113 <br />Oakdale, CA 95361 114, 115, 116 <br />2098471025 112 <br />Mountain Mikes Pizza 3 <br />1255 Lillian Ave 103 <br />Escalon 104 <br />95320 105 <br />209-838-8200 102 <br />161 North Second Ave 108a <br />Oakdale, CA 95361 108b, 108c, 108d <br />Maddox Resources <br />140 <br />161 North Second Ave <br />143 <br />Oakdale, CA 95361 <br />144, 145, 146 <br />2098471025 <br />141 <br />jcarlson429@gmail.com <br />142 <br />Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW <br />created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] 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: �01% P--3— Date: <br />Accounting: Reviewed by: t,16 Date: 5�/7 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 />1625 - RESTAURANT/BAR 51-100 SEATS PRO527490 KADEANNE LINHARES Active [ ] [ ] <br />1919 - HMBP-0O2 Only Food Facility 1 chem units PR0540403 KADEANNE LINHARES Active [ ] [ ] <br />