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Date ren 1/31/2013 2:19:01Pt, SAN H )UIN COUNTY ENVIRONMENTAL HEA` 1 DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 1/31/2013 <br /> Recon Selection Criteria'. Facility ID FA0017293 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI Fed Tax ID <br /> Owner ID OW0014134 New Owner ID <br /> Owner Name ELENORE BEDELL <br /> Owner DBA ELENORE BEDELL M M777al yr Q <br /> Owner Address 21944 S BURWOOD RD <br /> ESCALON, CA 95320 <br /> Home Phone Not Specified <br /> WorklBusiness Phone Not Specified <br /> Mailing Address 21944 S BURWOOD RD <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017293 <br /> Facility Name ELENORE BEDELL Pr I ( MS <br /> Location 21944 S BURWOOD RD <br /> ESCALON, CA 95320 <br /> Phone 209-838-3068 x0 <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 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 AR0030175 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name ELENORE BEDELL Circle Chat <br /> Account Balance as of 1/31/2013: $0.00 <br /> (Circle One) <br /> Transfer to pn' <br /> ProgranVElement and Description Record 10 Employee ID and Name Status New Oswi Delete <br /> HM-Farm Operations PRO625478 Inactive Y N -A I D <br /> 284V AST EXEMPT FAC < 1,320 GAL PRO529310 EE0000753-WILLY NG Active,Exempt Y N A I D <br /> SC-ELECTRONIC REPORTING STATE SURCHPR0531478 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that oil elle,anon protect specific,PHS/EHO hourly ctlerges associated with this facility <br /> or activity will ba billed to the party identified ea the OWNER on this form 1 also certify that all operations will in,performed in accordance with all applicable Ordinance Codes andor Standards end State ands <br /> Federal Laws <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Recei <br /> RENS: Date / / Account out: :' DateI ) / <br /> COMMENTS'. <br /> 13 113 <br />