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Date run 3/5/2014 10:17:14AM SAN JO. IN COUNTY ENVIRONMENTAL HEA1 DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/5/2014 <br /> Record Selection Criteria: Facility ID FA0001818 <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 OW0001421 New Owner ID <br /> Owner Name MEANS, LONNIE S JR <br /> Owner DBA BULLFROG LANDING MARINA <br /> Owner Address 17251 BACON ISLAND RD <br /> STOCKTON, CA 95219 <br /> Home Phone 925-457-8235 <br /> Work/Business Phone 209-465-9610 <br /> Mailing Address 17251 BACON ISLAND RD <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0001818 10,180,813 <br /> Facility Name BULLFROG LANDING MARINA <br /> Location 17251 BACON ISLAND RD <br /> STOCKTON, CA 95219 <br /> Phone 209-465-9610 <br /> Mailing Address 17251 BACON ISLAND RD <br /> STOCKTON, CA 95219 <br /> Care of MEANS, LONNIE S JR <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 12917003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CARL WENSKE <br /> Title <br /> Day Phone 209-465-9610 <br /> Night Phone 928-457-8235 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001823 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BULLFROG LANDING MARINA (Circle One) <br /> Account Balance as of 3/5/2014: $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 /> 1615-RETAIL MKT 301-2000 SQ FT(PREPKGD/LTD PF PRO160902 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0521083 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511980 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509692 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2831 -AST FAC >/= 1,320-<10 K GAL CUMULATIVE PRO516704 EE0001421 -STACY RIVERA Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532593 Inactive Y N A I D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0515586 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,and/or project specific,PHS/EHD hourly charges associated with this facility or <br /> 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 Ordinance Codes andvor Standards and State and/or 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 /> REHS: Date ! / Account out: Date <br /> COMMENTS: <br />