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Date run 5/16/2013 2:03:13Pk SAN JOAW COUNTY ENVIRONMENTAL HEAL EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/16/2013 <br /> Record Selection criteria: Facility ID FA0004414 <br /> Make changeVcorrectlons In RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0005881 New Own.eyr-ID <br /> Owner Name LS (BJrICl2pr a <br /> Owner DBA MOKELUMNE BEACH RV PARK <br /> Owner Addresscs a rnIRPi4Q F j oR ta:t .,A Ir&h; 94R 5 - <br /> Ia991. GA X6249cv . CaL. 95 3'14 <br /> Home Phone .2Q9 368_37} 209 GD(— 8Q"/ 4- <br /> Work/Business Phone 209-334-6729 ;L09 — 6o0( —//9,__0-01 4 <br /> Mailing Address 24a99Q 5 . L.dLv.N�F25 KW <br /> 69D�c' �52�0 —7Y�acy , Ca. q5_2 r77 <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 ����� rj 7a I" <br /> lti. S <br /> LG94-0248- 4C,4 . 99, 2,17 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 01709029 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name E) l/r S Trot rc PH t fI� <br /> Title -l.ns L_4 <br /> Day Phone 209-333-0340 <br /> Night Phone 209-368-3717 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION P EtvEp <br /> Account ID AR0010416 REC New Account ID: <br /> Mail Invoices to Facility SUN 2 2p13 Mail Invoices to: Owner / Facility / Account <br /> Account Name MOKELUMNE BEACH RV PARK U)NCOUN" (Circle One) <br /> Account Balance as of 5/16/2013: $0.00 5A EN Q NiEN7MEN7 <br /> AFL (Circle Orel <br /> EALSHOEP Transfer to Activerinactre <br /> ProgramfElemenl and Description Record ID H Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO520842 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0461238 EE0005838-ADRIENNE ELLSAESSEActive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORI7ATIOtPRO515859 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0461238 EE0005838-ADRIENNE ELLSAESSEActive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0515860 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0461238 EE0005838-ADRIENNE ELLSAESSEActive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO534698 Inactive Y N A I D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0461238 EE0005838-ADRIENNE ELLSAESSEActive Y N A I D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0461238 EE0005838-ADRIENNE ELLSAESSEActive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I.Ne undersigned owner,operator or agent of same,sconoMedge that all site,andor protect specific,PHSrEHD hourly chargee associated with this facility <br /> or.dwity will be billed to the party identified as the OWNE on this form I also certify that all operations will be performed in accordance with all appliiccarbleOrdinance Code andor Stan/ da and state <br /> andor �/ <br /> Federal Laws �rt t, _. 7" ��..s_. �y./i� (3 '4/ 1i` <br /> APPLICANT'S SIGNATURE: �- Y • D rLF/L .-elrD-a`tte /a� / -/3 (( «( (/ ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid516'9 Date l�/_E7!� <br /> Water System to be FERED: Amount Paid Date <br /> Payment Type Check Number 1 097 Receive4 by <br /> RENS: Date !_/_ Account out: <br /> COMMENTS: <br />