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Date run 2/k12013 10:29:25AI SAN JIR <br /> UIN COUNTY ENVONMENTAL HEe1�H DEPARTMENT Report#5021 <br /> Run by, Pagel <br /> Facility Information as of 2/11/2013 <br /> Record Selection Criteria: Facility ID FA0017293 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax lD <br /> Owner ID OW0014134 New Owner ID <br /> Owner Name ELENORE BEDELL <br /> Owner DBA ALCHICK FARMS <br /> Owner Address 21944 S BURWOOD RD <br /> ESCALON, CA 95320 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 21944 S BURWOOD RD <br /> ESCALON, CA 95320 <br /> Care of ELENORE BEDELL <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017293 <br /> Facility Name ALCHICK FARMS _ <br /> Location 21944 S BURWOOD RD <br /> ESCALON, CA 95320 V. <br /> Phone 209-838-3068 xO i <br /> Mailing Address 21944 S BURWOOD RD <br /> ESCALON, CA 95320 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 24724021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030175 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ELENORE BEDELL (Circle Ona) <br /> Account Balance as of 2/11/2013: $0.00 <br /> (Circle One) <br /> Transfer to ActivaAnache <br /> Prograrn Element and Description Record 10 Employee ID and Name Status New Owner/ Delete <br /> HM-Farm Operations PR0525478 Active Y N AD <br /> 2840 ST EXEMPT FAC < 1,320 GAL PRO529310 EE0000753-W ILLY NG Active,Exempt Y N A I D <br /> -ELECTRONIC REPORTING STATE SURCH�PRO531478 Inactive Y N A I 0 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the Perry identified as the OWNER on this form I also ce"that all operations will be performed in accordance with all applicable Ordinance Cortes ander Standards and State all <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Receiv d <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />