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Date run 7/29/2015 4:45:24PN SAN JC UIN COUNTY ENVIRONMENTAL HEA_ DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 7/29/2015 <br />Record Selection Criteria: Facility ID FA0003830 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID OW0002836 <br />Owner Name PEGASUS GROUP <br />Owner DBA VILLAGE WEST MARINA <br />OwnerAddress 6649 EMBARCADERO DR <br />STOCKTON, CA 95219 <br />Home Phone Not Specified <br />Work/Business Phone 925-930-0810 <br />Mailing Address 6649 EMBARCADERO DR <br />STOCKTON, CA 95219 <br />Care of <br />FACILITY FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) / <br />OWNERSHIP CHANGE (date)ZZ I <br />SSN / Fed Tax ID : <br />New Owner ID <br />Lest r .-i ✓�C� L.L C <br />D RA 0; 16Wes �Ltar� � eti -- <br />/ � Z u Myu S Frei <br />2I b b 3 <br />j_US-D 3(,9- (.P 7qb <br />S'-1-oGiG-i-ytn CA �S-ZI � <br />Site Mitigation Facility <br />Facility ID / CERS ID FA0003830 10181463 <br />Facility Name VILLAGE WEST MARINA <br />e? <br />Location 6649 EMBARCADERO DR <br />STOCKTON, CA 95219 <br />Phone 209-951-1551 x <br />Mailing Address 6649 EMBARCADERO DR <br />STOCKTON, CA 95219 <br />Care of VILLAGE WEST MARINA <br />Location Code 01-STOCKTON <br />Alt Phone <br />BOS District 002 - MILLER, KATHERINE <br />Fax <br />APN 09815006 <br />EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />�,rv� �F- I C t^a- <br />Title <br />n r c ohs tv � ,, r <br />Day Phone <br />(p N() ~ 3 J -,(D <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0003418 <br />New Account ID: : f�1�17003�11F1 <br />Mail Invoices to Account <br />Mail Invoices to: Owner / aclll� / Account <br />Account Name VILLAGE,,WE-ST MARINA <br />( ne) <br />Account Balance as of 7/29/2015; $-143.00 <br /><\ <br />(Circle One) <br />Transferto Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status New Owner? Delete <br />20 - HMBP-Common Materials PR0519700 <br />PR0517849 <br />EE0000006 - HAZA SAEED Active N A I D <br />EE0000005 FATINAH ZAREEF Active C6 N A I D <br />220 - M HW GEN <5 TONS/YR <br />- <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511812 <br />EE0000000 - HAZ MAT SJC OES Inactive N A I D <br />& <br />36 - UST FACILITY PR0231098 <br />EE0000005 - FATINAH ZAREEF Active N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FE PRO507487 <br />EE0000418 - MICHAEL KITH Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE PRO534358 <br />Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and(or project specific, PHS/EHD hourly charges associatt is facility or e <br />Standards State <br />be billed to the party identified as the OWNER on this form. I also certify that all operations will be <br />performed in accordance with all applicable Ordinance Codes andror and <br />Fjflr . <br />APPLICANT'S SIGNATURE: c(/ <br />Date l�D l SSAIV 3 0 <br />Program Records to be T NSFERED: _ " $25.00 = 7J <br />Amount Paid Date �l ' 0 l-- F 6V 'IQ('/fv C <br />ACTN <br />Water Syst be T SFERED: <br />Amount Paid Date l ped �p�+Vry <br />Pay nt T e Check Number <br />Received by lUj <br />Ea' Staff: Date .7 <br />/ . Account out: _Date <br />co N�i�� _ ' L <br />C� , � � n Invoice #: ?"(O'0 of 6� <br />bb -72D (7-- <br />