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Date run 1/24/2012 8:29:40AAReport#5021 <br /> SAN J/ `JIN COUNTY ENVIRONMENTAL HE, ' DEPARTMENT <br /> Run by. Pagel v <br /> Facility Information as of 1/24/201 <br /> Record Selection Criteria: Facility ID FA0002636 <br /> Make changes/corrections in RED ink. I I <br /> INFORMATION CHANGE(date) l <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0002000 New Owner ID <br /> Owner Name WINDMILL COVE RESORT/MARINALLC <br /> Owner DBA <br /> Owner Address 7600 WINDMILL COVE RD <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-948-6995 <br /> Mailing Address 7600 WINDMILL COVE RD <br /> STOCKTON, CA 95206 <br /> Care of THEIS, DAVID <br /> FACILITY FILE INFORMATION <br /> Facil;y ID FA0002636 <br /> Facility Name WINDMILL COVE RESORT/MARINA LLC <br /> Location 7600 WINDMILL COVE RD <br /> STOCKTON, CA 95206 <br /> Phone 209-948-6995 <br /> Mailing Address 7600 WINDMILL COVE RD <br /> STOCKTON, CA 95206 <br /> Care of THEIS, DAVID <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 13122008 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DAVID THEIS <br /> Title <br /> Day Phone 916-580-7520 <br /> Night Phone 916-663-9193 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002414 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WINDMILL C R ORT/MARINA LLC (Circle One) <br /> Account Balance as of 1/24/2012: $1 .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 /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO512312 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520032 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0510024 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2 -AST FAC 10 K-</=100 K GAL CUMULATIVEPRO516784 EE0001421 -STACY RIVERA Active Y N A I D <br /> SC-ELECTRONIC REPORTING STATE SURCHPR0533233 Active Y N A I D <br /> 4634-TNC WATER SYSTEM(QRTLY) WA0460616 EE0005838-ADRIENNE ELLSAESSEActive 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 /> age — - o g A-u L. ) C25o o <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid D to <br /> Payment Type Check Number Recei <br /> REHS. Date / // /0 Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />