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Date run 6/9/2010 10:06:18AIVI SAN JO IN COU +1T-Y•/ENVIRONMENTAL HEA/.— ')EPARTMENT Report#5021 <br /> Run by 4006k1.10 (-W� Pagel <br /> ,Facility Information as of 6/9/2010 <br /> Record Selection Criteria: Facility ID FA0001053 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION r+„ SSN/Fed Tax ID <br /> Owner ID OW0000824 `" New Owner ID <br /> Owner Name MARLOW, JOHN & MARIANNE <br /> Owner DBA ISLANDER MARINA <br /> Owner Address 750 LILAC LN <br /> SACRAMENTO, CA 95864 <br /> Home Phone Not Specified <br /> Work/Business Phone Not-Specified <br /> Mailing Address 750 LILAC LANE <br /> SACRAMENTO, CA 95864 <br /> Care of MARLOW, JOHN & MARIANNE <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0001053 <br /> Facility Name ISLANDER MARINA <br /> Location 20801 S WOODWARD AVE <br /> MANTECA, CA 95336 <br /> Phone <br /> Mailing Address p&'� � S 3`� <br /> Care of MARLOW, JOHN & MARIANNE <br /> Location Code 99- UNINCORPORATED p Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN 24125033 Entail: <br /> r <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001051 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name ISLANDER MARINA (Circle One) <br /> Account Balance as of 61912010: $1,107.00 <br /> (Circle One) <br /> Transfer to Aciivellnactve <br /> ProgramlEtement and Description Record ID Employee ID and Name Status New Owner/ Delete <br /> 4242-WASTE WATER TX PLANT PR0420073 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4622-25-99 SERVICE CONNECTIONS(CWS) WA0460653 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,PHSlEHD 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: S e_L. (3\�Ck," 0.nl;, ",V.,6D Date 1 I 4 <br /> Program Records to be TRANSFERED: *$20.00 Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: "$372.00 Amount Paid Date 1 I <br /> Payment Type Check Number Received by <br /> REHS: Date I I Account out: Date !_�! ) <br /> ]I COMMENTS: <br /> X11 envlenvisionlrel)orLS15021.rpt" -��. <br />