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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard Date run: 10/27/2016 <br /> Submitted on: 10/26/2016 12:45:27PM CERS ID: 10180633 <br /> Submitted by: Richard Hirsch Email: rahirsch@sbcglobal.net Facility ID in CERS: FA0000645 <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 OW0000515 <br /> Owner name Doreen S. Hirsch Kaur Surinder 111 <br /> Mailing address 20 W TURNER RDA 20 W TURNER RDA 113 <br /> LODI, CA 95240 LODI, CA 95240 114, 115, 116 <br /> Work phone 209-369-3697 209-369-3697 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000645 <br /> Facility name SHORT STOP FOOD MART SHORT STOP FOOD MART 3 <br /> Site address 20 W TURNER RDA 20 W TURNER RDA 103 <br /> City LODI LODI 104 <br /> ZIP code 95240 95240 105 <br /> Facility phone 209-369-3697 209-369-3697 102 <br /> Facility mailing address 20 W TURNER RD A 20 W TURNER RD A 108a <br /> LODI, CA 95240 LODI, CA 95240 108b, 108c,108d <br /> BILLING INFORMATION <br /> Contact name Doreen S. Hirsch Daily K. Gupta 140 <br /> Address 20 W TURNER RDA 20 W TURNER RDA 143 <br /> LODI, CA 95240 LODI, CA 95240 144, 145, 146 <br /> Contact phone 209-369-3697 209-369-3697 141 <br /> Contact email dshartist@sbcglobal.net dshartist@sbcglobal.net 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: I !!I <br /> - - - ------------- ---- - - - - -- - <br /> Accounting: Reviewed by: Lb Date: 10)29)1 b Clerical: [ ] File [ ] Relabel file [ ] 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 /> 1617-RETAIL MARKET>1000 SO FT W/FOOD PREP PRO160279 STEPHANIE RAMIREZ Active [ ] [ ] <br /> 1921 -HMBP-Regular-Primary Location PRO520474 JAMIE LIMA Active [ ] [ ] <br /> 2220-SM HW GEN<5 TONS/YR PRO518595 FATINAH ZAREEF Active [ ] [ ] <br /> 2361 -UST FACILITY PR0231380 FATINAH ZAREEF Active [ ] [ ] <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513052 HAZ MAT SJC DES Inactive [ ] [ ] <br /> 2301 -UST STATE SURCHARGE FEE PRO516160 FATINAH ZAREEF Inactive [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0507255 FATINAH ZAREEF Inactive [ ] [ ) <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0531842 not assigned Inactive [ ] [ ] <br /> 10127htf : Wo " of OWW yk* yew Irs in Pa.A'n OWf Per <br />