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Dale run 1/24/2011 10:52:56AI SAN.IOC'-"UIN COUNTY ENVIRONMENTAL.HEAI"TI DEPARTMENT Report#5024 <br /> Ran by 5280 tji101 Paget <br /> Facility Information as of 1124120`101" <br /> Record Selection Criteria: Facility ID FA0016727 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN!Fed Tax ID <br /> Owner ID OW0013568 New Owner ID <br /> Owner Name MAHIL FARMS <br /> Owner DBA MAHIL FARMS <br /> Owner Address 30814 AVE 9 <br /> MADERA, CA 93637 <br /> Home Phone Not Specified <br /> WorklBusiness Phone Not Specified <br /> Mailing Address 30814 AVE 9 <br /> MADERA, CA 93637 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016727 <br /> Facility Name MAHIL FARMS <br /> Location),1383 N KENNEFICK RD 2.�3 83 ic7V�l1� CK <br /> ACAMPO, CA 95220 <br /> Phone 559-674-9999 x0 <br /> Mailing Address 30814 AVE 9 <br /> MADERA, CA 93637 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 01705008 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 AR0029609 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name MAHIL FARMS (circle one) <br /> Account Balance as of 1/24/2011* $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO524912 Active Y N A I D <br /> /2840-AST EXEMPT FAC <1,320 GAL PRO530432 EE0000753-WILLY NG Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0532422 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,PHSIEHD hourly charges associated with this <br /> facility or activity will be billed to the party identETied as the OWNER on this form. i also certify that all operations will be performed in accordance 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: '$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date / 1 <br /> Payment Type Check Number Recei ed y <br /> REHS: Date ! I Account out: Date 1 1 Z`tF I l <br /> COMMENTS: f a <br /> 11eh-envlenvisionlreports15021.rpt <br />