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Report#5021 <br /> Date run 4122!2008 4:21:27PA SAN 5� ,UIN COUNTY ENVIRONMENTAL JEA �1 DEPARTMENT- Page <br /> Run by ice/ Facility Information as of 4/22/2008 <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 <br /> Owner ID OW0000176 New Owner ID <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 /> Work/Business 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 APN:21332002 <br /> BOS District 005- ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000210 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name MOSSDALE MARINA (Circle One) <br /> Account Balance as of 4/22/2008: $0.00 <br /> (Circle One) <br /> Transfer to Activellnacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANTIBAR 1-20 SEATS PRO161034 EE0001699-JOHNNY YOAKUM Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARiPR0516717 EE0009903-DOUG WILSON Inacti Y N A �D <br /> 2836-AST FAC>/=100 M+ 1 GAL CUMULATIVE PRO516716 EE0005642-MICHELLE HENRY Activ Y N A D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0460904 EE0005838-ADRIENNE ELLSAESS ctive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or oject specific,PHSIEHD 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 accordan a with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid D to / 1 <br /> Water System to be TRANSFERED: *$372.00= Amount Paid D to 1 1 <br /> Payment Type Check Number Receiv d <br /> RENS: Date ! 1 Account out: Date <br /> COMMENTS: <br /> A y <br /> Ilphs-ehsql-ntlappslenvisionslreports15021.rpt <br />