Laserfiche WebLink
Date run 9/22/2004 4:21:34PK SAN X _UIN COUNTY ENVIRONMENTAL HEAD_d DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/22/2004 <br /> Record Selection Criteria: Facility ID FA0003034 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002265 New Owner ID <br /> Owner Name LOST ISLE PARTNERS <br /> Owner DBA LOST ISLE <br /> Owner Address 20520 PROSPECT RD 200 <br /> SACRAMENTO, CA 950703019 <br /> Home Phone 510-634-4139 <br /> Work/Business Phone 408-446-8300 <br /> Mailing Address 4555 N PERSHING AVE#33-211 <br /> STOCKTON, CA 95207 <br /> Care of DAVE WHEELER OR DICK CHILDRESS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003034 <br /> Facility Name LOST ISLE RESORT <br /> Location 11050 ACKER ISLAND RIVER RTE <br /> STOCKTON, CA 95206 <br /> Phone 209-948-4135 <br /> Mailing Address 4555 N PERSHING AVE#33-211 <br /> STOCKTON, CA 95207 <br /> Care of DAVE WHEELER OR DICK CHILDRESS <br /> Location Code 99 - UNINCORPORATED AREA APN:13102001 <br /> BOS District 003- MOW, VICTOR SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002597 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LOST ISLE RESORT (Circle One) <br /> Account Balance as of 9/22/2004: $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 /> 1624-RESTAURANT/BAR 21-50 SEATS PRO160762 EE0003361 -MARIBEL FLOHRSCHU-Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0521899 Active Y N A I D <br /> 4633-TNC WATER SYSTEM WA0460651 EE0000753-WILLIE NG 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\a pps\envisions\reports\5021.rpt <br />