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SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> Changes to EnvisionConnect by CERS lotegration Wizard Date run: 8/4/2014 <br /> Submitted on: 8/1/2014 3:49:32PM PK tv CERS ID: 10181295 <br /> Submitted by: zafar khan Email: zafarmalik82@yahoo.com ``1L �NEacility ID in CERS: FA0003677 <br /> Information prior to CIW processing 6�t Information after CIW processing CERS <br /> (current EC database) eft submittal) field <br /> OWNER INFORMATION \ <br /> Owner ID OW0017790 111 <br /> Owner name HAMED, KAMAL ISMAIL ZAFAR KHAN <br /> Mailing address 103 E BARRYMORE ST 824 E YOSEMITE AVE 114, 1153116 <br /> STOCKTON, CA 95204 MANTECA, CA 95336 <br /> Work phone 209-471-5233 (209) 271-2019 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003677 <br /> Facility name QUICK& EASY FOOD MART QUICK& EASY FOOD MART 3 <br /> Site address 824 E YOSEMITE AVE 824 E YOSEMITE AVE 103 <br /> 104 <br /> City MANTECA MANTECA 105 <br /> Zip code 95336 95336 <br /> Facility phone 209-823-8800 (209) 823-8800 102 <br /> Facility mailing address 824 E YOSEMITE AVE 824 E YOSEMITE AVE 108a <br /> MANTECA, CA 95336 MANTECA, CA 95336 108b,108c,108d <br /> BILLING INFORMATION <br /> Contact name QUICK& EASY FOOD MART QUICK& EASY FOOD MART 140 <br /> Address 824 E YOSEMITE AVE 824 E YOSEMITE AVE taa, 14531as <br /> MANTECA, CA 95336 MANTECA, CA 95336 141 <br /> Contact phone 209-823-8800 (209) 271-2019 <br /> Contact email kamal.hamed@yahoo.com zafarmalik82@yahoo.com 142 <br /> Mail invoices to Facility <br /> Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] 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: <br /> — ------------Y------------- <br /> Accounting: Reviewed by:_�Date: Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> .{ �AssEbilleEi- [ ,, SQ 9hars g : Date: <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1617-RETAIL MARKET>1000 SQ FT W/FOOD PREP PR0505505 LISA MEDINA Active I 1 [ 1 <br /> 1920-HMBP-Common Materials PR0530799 MICHAEL PARISSI Active [ 1 I 1 <br /> 1921 -HMBP-Regular-Primary Location PRO622041 MICHAEL PARISSI Inactive [ 1 [ 1 <br /> 2220-SM HW GEN<5 TONS/YR PR0518762 ELENA MANZO Active [ 1 I ] <br /> 2301 -UST STATE SURCHARGE FEE PR0508292 ALISON YOUNGBLOOD Inactive [ ] [ 1 <br /> 2361 -UST FACILITY PR0231459 ELENAMANZO Active [ 1 I1 <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0507395 ALISON YOUNGBLOOD Inactive [ 1 [ 1 <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PRO532387 not assigned Inactive I 1 I 1 <br /> !v #I loll D�l <br /> � � l <br />