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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Changes to EnvisionConnect by CERS Integration Wizard <br />Date run: 10/12/201 <br />Submitted on: 10/6/2015 2:49:23PM <br />Submitted by: Luis Viscarra Email: Iviscarra@rubios.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 />OW0011930 <br />Rubios Fresh Mexican Grill <br />1902 Wright Place. Suite 300 <br />Carlsbad, CA 92008 <br />760-929-8226 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0019026 <br />Facility name <br />RUBIOS RESTAURANT <br />Site address <br />5779 PACIFIC AVE STE 105 <br />City <br />STOCKTON <br />ZIP code <br />95207 <br />Facility phone <br />209-957-5606 <br />Facility mailing address 1902 WRIGHT PL <br />CARLSBAD, CA 92008 <br />BILLING INFORMATION <br />Contact name RUBIOS RESTAURANT <br />Address 1902 WRIGHT PL <br />CARLSBAD, CA 92008 <br />Contact phone 925-519-9165 <br />Contact email <br />Mail invoices to Facility <br />CERS ID: 10187041 <br />Facility ID in CERS: FA0019026 <br />Information after CIW processing CERS <br />(current submittal) field <br />RUBIOS RESTAURANT INC 111 <br />1902 WRIGHT PL 113 <br />CARLSBAD, CA 92008 114, 115, 116 <br />760-602-3600 112 <br />RUBIOS RESTAURANT STORE 232 3 <br />5779 PACIFIC AVE STE 105 103 <br />STOCKTON 104 <br />95207 105 <br />760-602-3600 102 <br />5779 Pacific Ave. Suite 105 108a <br />Stockton, CA 95207 1085. 108c. 108d <br />RUBIOS RESTAURANT 140 <br />1902 WRIGHT PL 143 <br />CARLSBAD, CA 92008 144, 145, 146 <br />760-602-3600 141 <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: Date: (0 1 t 7 <br />Accounting: Reviewed by: bi"? Date: Clerical: [ ] File [ ] Relabel file [ ] Create new file <br />[ ] Acct billed [ ] Surcharge verified By: Date: <br />ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br />Program Element and Description Record ID Employee name Status Reactivated Inactivated <br />1625 - RESTAURANT/BAR 51-100 SEATS PRO528098 VIDAL PEDRAZA Active [ ] [ ] <br />1921 - HMBP-Regular-Primary Location PR0530851 PETER LOMBARDI Active [ ] [ ] <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE FI PR0534302 not assigned Inactive [ ] [ ] <br />