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F <br /> un 9/22/2014 1:53:04Ph SAN Jf ,UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> y ]I( 9 <br /> Facility Information as of 9/22/2014 Pagel <br /> Record Selection Criteria Facility ID FA0012039 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008135 Case Number: H06803 New Owner ID <br /> Owner Name TOUCHSTONE GOLF <br /> Owner DBA <br /> Owner Address 11450 GOLF LINKS RD <br /> OAKLAND, CA 94605 <br /> Home Phone Not Specified <br /> Work/Business Phone 512-351-9264 <br /> Mailing Address 6301 W EIGHT MILE RD <br /> STOCKTON, CA 95219-8702 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012039 10184149 <br /> Facility Name RESERVE AT SPANOS PARK, THE <br /> Location 6301 W EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Phone 209-477-4653 <br /> Mailing Address 6301 W EIGHT MILE RD <br /> STOCKTON, CA 952198702 <br /> Care of WALSH. TIM <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 05528001 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name WALSH, TIM <br /> Title <br /> Day Phone 209-477-4653 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019142 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name RESERVE AT SPANOS PARK, THE (Circle One) <br /> Account Balance as of 9/22/2014: $0.00 <br /> (Circle one) <br /> Transfer to Active/Inactve <br /> Progra"Element and Description Record IO Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PR0515086 EE0005362-NICHOLAS WIESEMAN Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO520365 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO522606 EE0001422-ARTS VELOSO Active Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO519136 EE0001699-JOHNNY YOAKUM Inactiv( Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533055 Inactiv[ Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHSIEHD hourly charges associated with this facility <br /> or activity,will be billed to the party identified as the OWNER an this forth. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date_/ / Account out: Date / / <br /> COMMENTS: <br />