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Date run 12/29/2022 9:49:32A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/29/2022 <br /> Record Selection Criteria: Facility ID FA0021104 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0017373 New Owner ID : <br /> Owner Name HARRIGAN, THOMAS D <br /> Owner DBA EL CAMINO BOAT CLUB <br /> OwnerAddress 108 CHAMBERSBURG WAY <br /> FOLSOM, CA 95630 <br /> Work/Business Phone 916-223-7665 <br /> Alternative Phone 916-984-8686 <br /> Mailing Address PO BOX 923 <br /> SAN MATEO, CA 94403 <br /> Care of <br /> FACILITY FILE INFORMATION APN <br /> Facility ID/CERS ID FA0021104 <br /> Facility Name EL CAMINO BOAT CLUB <br /> Location EL CAMINO ISLAND <br /> LODI, CA 95240 <br /> Phone 916-984-8686 <br /> Mailing Address PO BOX 923 O F36x 7-2- 711 <br /> SAN MATEO, CA 94403 Cs%u.. K' &J , c/1 <br /> Care of THOMAS HARRIGAN y ,-"4( c ey <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name THOMAS HARRIGAN <br /> Title COMMODORE <br /> Day Phone 916-984-8686 <br /> Night Phone 916-223-7665 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0038018 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name EL CAMINO BOAT CLUB (Circle One) <br /> Email invoice to(up to 2 emails) ALI7FREEMAN@AOL.COM; DUKHUNT33@( <br /> Email permit to(up to 2 emails) ALI7FREEMAN@AOL.COM; DUKHUNT33@( <br /> Account Balance as of 12/29/2022: $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 /> 4244-PUMPER TRUCK PR0536737 EE0000034-NASEEM AHMED Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ancifor 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 will be performed in accordance with all applicable Ordinance Codes andcor Standards and State and/or <br /> Federal Laws. <br /> APPLICANTS 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 /> EHD Staff: Date / 13 / Zj Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />