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Data' <br />run /10/2010 9:48:OOAN SAN JC 'JIN COUNTY ENVIRONMENTAL HEA' 1 DEPARTMENT Report #5021 <br />Run by - Pagel <br />Facility Information as of 2/10/201 <br />Record Selection Criteria: Facility ID FA0003366 <br />"IL <br />OWNER FILE INFORMATION - <br />Owner ID OW0002492 Case Number: 002443 <br />Owner Name <br />BADER DAIRY <br />Owner DBA <br />BADER DAIRY <br />Owner Address <br />23628 E MARIPOSA RD <br />EE0004589 - KADEANNE LINHARES Inactive <br />ESCALON, CA 95320 <br />Home Phone <br />209-499-7475 <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />23628 E MARIPOSA RD <br />I D <br />ESCALON, CA 95320 <br />Care of <br />Y N <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0003366 <br />Facility Name <br />BADER DAIRY <br />Location <br />23662 E MARIPOSA RD <br />ERSC - ELECTRONIC REPORTING SURCHARGE PR0532936 <br />ESCALON, CA 95320 <br />Phone <br />209-499-7475 <br />Mailing Address <br />D <br />E GAI r,.� r�l <br />Care of <br />certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards <br />Location Code <br />99 - UNINCORPORATED A <br />BOS District <br />004 - VOGEL, KEN <br />APN <br />20717009 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name FRAGOSO, LUIS <br />Title <br />Day Phone 209-499-7475 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0002943 <br />Mail Invoices to Facility <br />Account Name BADER DAIRY <br />Account Balance as of 2/10/2010: $280.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Q-0. C) -n -x $a5 <br />L..)dc' �c S S3— D82� <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />Program/Element and Description Record ID <br />Employee ID and Name Status <br />Transfer to <br />New Owner? <br />(Circle One) <br />Active/Inaclve <br />Delete <br />2011 - GRADE A DAIRY PR0200056 <br />EE0004589 - KADEANNE LINHARES Inactive <br />Y N <br />A <br />I D <br />2220 - SM HW GEN <5 TONS/YR PR0529339 <br />EE0002670 - MUNIAPPA NAIDU Active <br />Y N <br />A <br />I D <br />2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525886 <br />Active <br />Y N <br />A <br />I D <br />2830 - AST FAC - SPCC EXEMPT PR0529317 <br />EE0002670 - MUNIAPPA NAIDU Active,Exempt <br />Y N <br />A <br />I D <br />ERSC - ELECTRONIC REPORTING SURCHARGE PR0532936 <br />Active <br />Y N <br />A <br />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 <br />certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards <br />and <br />State and/or Federal Laws. <br />-\ APPLICANT'S SIGNATURE: S e e. �O' � .`t` -so 4 v Date <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS <br />\\e h-env\envision \reports\50 21. rp t <br />' $20.00 = <br />* $372.00 = <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Received by <br />Account out: W-r� Date 2-- / \0 / 0 <br />