Laserfiche WebLink
Date run 6/19/2013 10:04:40A1 $AN JOAQ <br /> Run r *COUNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> Report#5021 <br /> Facility Information as of 6/19/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0004414 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0005881 New Owner ID : 1 <br /> Owner Name �US9Z�� t-�tQeyltV7� <br /> Owner DBA MOKELUMNE BEACH RV PARK J <br /> Owner Address A <br /> Home Phone-4209-322 2747 <br /> Work/Business Phone 2998346729 Q _ <br /> Mailing Address 755 S FAIRMONT AVE STE Al <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0004414 10,181,623 <br /> Facility Name MOKELUMNE BEACH RV PARK <br /> Location 18450 N HWY 99 FRONTAGE RD <br /> ACAMPO, CA 95220 <br /> Phone 209-333-0340 x0 <br /> Mailing Address 755 S FAIRMONT AVE A-1 <br /> LODI, CA 95240 �06Lsi_ 95-377 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 01709029 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone-^^�.o�yv- <br /> Night Phones <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0010416 NewAccount ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MOKELUMNE BEACH RV PARK (Circle one) <br /> Account Balance as of 6/19/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0520842 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0515859 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO515860 EED004636-GARRETT BACKUS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534698 Inactive Y N A I D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0461238 EE0005838-ADRIENNE ELLSAESSER Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that all operations win be performed in accordance with all applicable Ordinance Codes andfor Standards and Slate 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 />