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Date run 8/25/2003 1:45:55PN SAN J( UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by � Pagel <br /> Facility Information as of 8/25/2"3 <br /> Record Selection Criteria: Facility ID FA0004091 de <br /> ®� Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0003007 New Owner ID <br /> Owner Name WESTREC PROPERTIES INC <br /> Owner DBA TOWER PARK MARINA <br /> Owner Address 6400 LAUREL CANYON BLVD <br /> N HOLLYWOOD, CA 91606 <br /> Home Phone 818-753-0400 <br /> Work/Business Phone 209-369-1041 <br /> Mailing Address 6400 LAUREL CANYON BL STE 200 <br /> N HOLLYWOOD, CA 91606 <br /> Care of DON MCSHANE <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004091 <br /> Facility Name TOWER PARK MARINA <br /> Location 14900 W HWY 12 <br /> LODI, CA 95242 <br /> Phone 209-369-1041 <br /> Mailing Address 14900 W HWY 12 <br /> LODI, CA 95242 <br /> Care of JAMES MILLS <br /> Location Code 99 - UNINCORPORATED AREA APN: <br /> BOS District 004 - SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003751 New Account ID: <br /> Mail Invoices to Facility I s to: Owner / Facility / Account <br /> Account Name TOW E � INA ; � / (Circle one) <br /> Account Balance as of 8/25/200 8-81T <br /> (Cirri <br /> Transfer to Acti /lnactve <br /> Program/Element and Description , Record ID Employee ID and Name _ Status New Owner? <br /> 2960-RWQCB CLEAN UP SITE(SLIC) PR0009023 EE0000684-MICHAEL INFURNA 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 <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. <br /> APPLICANT'S SIGNATURE: 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-ehsql-nt\apps\Envision s\Reports\5021.rpt <br />