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Date run 7/7/2008 3:20:10PM SAT `)AQUIN COUNTY ENVIRONMENTAL P %LTH DEPARTMENT Report*W21 <br /> Run by w"t <br /> Facility Information as of 7108 Pagel <br /> Record Selection Criteria: Facility ID FA0000220 <br /> Make changes/corrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID : <br /> Owner ID OW0000176 New Owner I <br /> Owner Name RADFORD, THOMAS <br /> Owner DBA MOSSDALE MARINA <br /> Owner Address 324 GRAND PRIX <br /> MANTECA, CA 95336 <br /> Home Phone 209-982-0512 <br /> WorklBusiness Phone 209-982-0512 <br /> Mailing Address 324 GRAND PRIX <br /> MANTECA, CA 95336 <br /> Care of RADFORD, THOMAS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000220 <br /> Facility Name MOSSDALE MARINA <br /> Location 73 W STEWART RD <br /> LATHROP, CA 95330 <br /> Phone 209-982-0512 <br /> Mailing Address 73 W STEWART RD <br /> LATHROP, CA 95330 <br /> Care of RADFORD, THOMAS E <br /> Location Code 07-LATHROP Alt Phone <br /> BOS District 005 -ORNELLAS, LEROY Fax <br /> APN 21332002 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000219 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name MOSSDALE MARINA (Circle One) <br /> Account Balance as of 71712008: $0.00 <br /> (Circle one) <br /> Transfer to Adivennacrie <br /> Program/Element and Description Reoord ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANTIBAR 1-20 SEATS PR0161034 EE0001699-JOHNNY YOAKUM Inactive Y N A I D <br /> 239 -UNIFIED PROGRAM FAG STATE SURCHARPR0516717 EE0009903-DOUG WILSON Inactive Y N A I D <br /> 2831 AST FAC >I=1,320-<10 K GAL CUMULATI1PRo516716 EE0005642-MICHELLE HENRY Inactive Y N A I D <br /> TNC WATER SYSTEM(QRTLY) WA0460904 EE0005838-ADRIENNE ELLSAESSEInactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSlEHD hourly charges associated with this <br /> facility or activity will be Niled to the party identified as the OWNER on this form. I also certify that all operations vriN be performed in accordance with all applicable ordinate Codes andlor Standards and <br /> State andlor Federal Laws. <br /> A%V <br /> APPLICANT'S SIGNATURE: Date 1 ! <br /> Program Records to be TRANSFERED: $20.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date 1 1 <br /> Payment Type Check Number Received y <br /> REHS: Date I I Account out: Date 1� 1 <br /> COMMENTS: <br /> Ilphs-ehsq[-n t\apps\envisions\reportsk502l.rpt <br />