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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 4/19/2016 <br /> Submitted on: 2/24/2016 4:15:32PM CERS ID: 10184561 <br /> Submitted by: BETH GRUBA Email: bethg@harmans.com Facility ID in CERS: FA0014100 <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 OW0011163 <br /> Owner name FROILAN 284 INC Froilan 284, Inc. 111 <br /> Mailing address 8334 GERBER RD 1555 Meadowview Road, Suite 150 113 <br /> SACRAMENTO, CA 95828 Sacramento, CA 95832 114, 115, 116 <br /> Work phone 916-689-2190 916-553-2267 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014100 <br /> Facility name KFC/A&W#284 KFC/A&W#284 3 <br /> Site address 4450 E WATERLOO RD 4450 E WATERLOO RD 103 <br /> City STOCKTON STOCKTON 104 <br /> ZIP code 95215-2306 95215-2306 105 <br /> Facility phone 209-931-8994 209-931-8994 102 <br /> Facility mailing address 8334 GERBER RD 1555 Meadowview Road, Suite 150 108a <br /> SACRAMENTO, CA 95828-3710 Sacramento, CA 95823 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name FROILAN 284 INC Froilan 284, Inc. 140 <br /> Address P.O. BOX 572530 c/o 1555 Meadowview Road, Suite 150 143 <br /> SALT LAKE CITY, Sacramento, CA 95723 144, 145, 146 <br /> Contact phone 801-313-8000 916-553-2267 141 <br /> Contact email 142 <br /> Mail invoices to Account <br /> Program record [ ] HMBP [ ] SQG HW [ ] LOG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ j APSA [ ] CalARP [ ] UST New PE: <br /> Assigned to: <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendarear <br /> y [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: I!n Date: 41 J[ <br /> --- -- — — -- -- — -- — — — -- <br /> Accounting: Reviewed by: Date: 2 Clerical: [ ] File [ ] Relabel file [ j Create new file <br /> [ ] Acct billed [ ] Surcharge verified By: Date: <br /> ---------------------------- <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 PR0518724 LEYNA HUYNH Active [ ] [ ] <br /> 1919-HMBP-0O2 Only Food Facility PR0521250 LEYNA HUYNH Active [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0518726 Inactive [ ] [ ] <br /> 3116-STORMWATER INSPECTION-FOOD PR0523053 VIDAL PEDRAZA Inactive [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0531761 not assigned Inactive [ ] [ ] <br />