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Date run 2/19/2004 4:14:33PN SAN JOAW COUNTY ENVIRONMENTAL HEAL EPARTMENT Report usort <br /> Run by Pagel <br /> Facility Information as of 2/19/200 <br /> Record Selection Criteria: Facility ID FA0004175 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION r� <br /> Owner ID OW0001047 ( � New Owner ID <br /> Owner Name HANF, HORST <br /> Owner DBA TIKI LAGUN RESORT& MARINA <br /> Owner Address 834 FRANCISCO WEST <br /> SAN RAFAEL, CA 94901 <br /> Home Phone Not Specified <br /> Work/Business Phone 415-456-5000 <br /> Mailing Address l O ( c?p-Co S i L, CT <br /> r► I" r[ � CA' 94S3Y -1W73 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0004175 <br /> Facility Name TIKI LAGUN RESORT& MARINA <br /> Location 12988 W MCDONALD RD <br /> STOCKTON, CA 95206 <br /> Phone 209-941-8975 /1 <br /> Mailing Address �/rI <br /> SA RA AAL,li� <br /> Care of <br /> Location Code 99- UNINCORPORATED AREA APN: <br /> BOS District 003 - MOW, VICTOR SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004255 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TIKI LAGUN RESORT& MARINA (Circle One) <br /> Account Balance as of 2/19/2004: $339.00 <br /> (Circle One) <br /> Transfer to <br /> Aative/InecNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1616-RETAIL MARKET<1000 SQ FT W/FOOD PPRO160928 EE0003361 -MARIBEL FLOHRSCHU-Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0511642 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519572 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84) PR0231679 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2390-ABOVEGROUND TANK(SPCC) PRO516680 EE0007289-ALISON YOUNGBLOODAcdve Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO509354 EE0007289-ALISON YOUNGBLOODInactive Y N A I D <br /> 4653-TNC WATER SYSTEM W/iX WA0460583 EE0005838-ADRIENNE ELLSAESSEActive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all ske,andlor project speck,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. fl <br /> (l D � p q <br /> APPLICANT'S SIGNATURE: I (l A-t L- V-e `uili3 Date <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsq I-nt\apps\Envisions\Reports\5021.rpt <br />