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Date run 7/19/2012 10:48:02AI SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTli DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/19/2(, <br /> Record Selection Criteria: Facility ID FA0004175 <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 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 <br /> Mailing Address 6243 EMBARCADERO DR <br /> STOCKTON, CA 95219 <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 209-464-2980 <br /> Mailing Address 6243 EMBARCADERO DR me <br /> STOCKTON, CA 95219 c1 tJ <br /> Care of TIKI LAGUN PARTNERS LLC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS 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 / Account <br /> Account Name TIKI LAGUN RESORT& MARINA (Circle One) <br /> Account Balance as of 7/19/2012: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1616-RETAIL MARKET<1000 SQ FT W/FOOD PfPR0160928 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1 X21gP-Regular-Primary Location PIRQ519572 EE0002474-MICHAEL P�RtS>3Y Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0528550 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0511642 EE0000000-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 SURCHAR(PR0509354 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVEPRO516680 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 SURCH,PR0534038 Active Y N A I D <br /> 4633-TNC WATER SYSTEM WA0460583 EE0005838-ADRIENNE ELLSAESSEActive Y N A I D <br />