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Date run 2/13/201$ 11:48:57AI SAN JCO[JIN COUNTY ENVIRONMENTAL HEAO DEPARTMENT <br /> Report#5021 <br /> Run bY . Pagel <br /> Facility Information as of 2/13/2014 <br /> Record Selection Criteria: Facility ID FA0004175 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0001047 New Owner ID <br /> Owner Name TIKI LAGUN PARTNERS LLC <br /> Owner DBA TIKI LAGUN RESORT & MARINA <br /> Owner Address 6243 EMBARCADERO DR <br /> STOCKTON, CA 95219 <br /> Home Phone 209-601-4538 <br /> Work/Business Phone 209-464-2980 1 <br /> Mailing Address 3`t'(o 1 r oohs icle KrJ 5--c A <br /> S�nc.k-(-ons Ck< SIS -2-19 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility lD/CERS ID FA0004175 10,181,603 <br /> Facility Name TIKI LAGUN RESORT& MARINA <br /> Location 12988 W MCDONALD RD <br /> STOCKTON, CA 95206 <br /> Phone 209-464-2980 1 <br /> Mailing Address �j4t.1 �cUO1e..S1�� tip. • SA-e-A <br /> STOCKTON, CA 19 S10 Cp- 9S119 <br /> Care of TIKI LAGUN PARTNERS LLC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> SOS District 003 - BESTOLARIDES Fax <br /> APN 13102026 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FAX#(415)456-5250 <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004255 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name TIKI LAGUN RESORT & MARINA (Circle One) <br /> Account Balance as of 2/13/2014: $1,238.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> PrograMElemenl and DescriptionRecord ID Employee ID and Name Status New Owner! Delete <br /> 1616-RETAIL MARKET<1000 SO FT W/FOOD PREP PRO160928 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO519572 EE0008709-JAMIE DE LA ROSA Active Y N A 1 D <br /> 2220-SM HW GEN<5 TONS/YR PRO528550 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511642 EE00o0000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231679 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509354 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVE PRO516680 EE0001421 -STACY RIVERA Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0523808 EE5555555-Garrett Alias-Backus Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534038 Inactive Y N A I D <br /> 4633-TNC WATER SYSTEM WA0460583 EE0005838-ADRIENNE ELLSAESSER Active Y N A I D <br />