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APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: *$25.00 = <br />Water System to be TRANSFERED: <br />Payment Type au er <br />EHD Staff: ,A i4f <br />COMMENTS: <br />Receiv d b <br />Date / / 24 Account out: <br />Amount Paid <br />Amount Paid <br />Date <br /> Date <br />:EMS (" <br />c tAftde <br />( 2.02A <br />Date / / //0 2- <br />Invoice #: <br />'Date run 9/1/2021 12:09:00PM <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report #5021 <br />Run by <br />Facility Information as of 9/1/2021 <br /> Pagel <br />Record Selection Criteria: Facility ID <br />FAO 024683 <br />Make changes/corrections in RED ink. <br /> <br />INFORMATION CHANGE (date) <br /> <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />Owner Name <br />Owner DBA <br />Owner Address <br />Work/Business Phone <br />Alternative Phone <br />Mailing Address <br />Care of <br />OW0023291 <br />AMB RANCH MANAGEMENT <br />AMB AG ENTERPRISE <br />28806 AVE 15 <br />MADERA, CA 93638 <br />Not Specified <br />559-674-5400 <br />28806 AVE 15 <br />MADERA, CA 93638 <br />TRUJILLO, ELI <br />SSN / Fed Tax ID : <br />New Owner ID : <br />FACILITY FILE INFORMATION APN <br />Facility ID! CERS ID <br />Facility Name <br />Location <br />Phone <br />Mailing Address <br />Care of <br />FA0024683 <br />AMB AG ENTERPRISE <br />28806 AVE 15 RD <br />MADERA, CA 95638 <br />559-674-5400 <br />28806 AVE 15 RD <br />MADERA, CA 95638 <br />NAVARRO, MARIAH <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />Hernandez, Abigail <br /> <br />559-674-5400 <br />559-363-9042 <br /> <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0046188 <br />Mail Invoices to Facility <br />Account Name AMB AG ENTERPRISE <br />Email invoice to (up to 2 emails) AMB.MNAVARRO@GMAI L.COM <br />Email permit to (up to 2 emails) AMB.MNAVA RO@GMAIL.COM <br />Account Balance as of 9/1/2021: $ 00 <br />Program/Element and Description Record ID Employee ID and Name <br />New Account ID: <br />Mail Invoices to Owner / Facility / Account <br />(Circle One) <br />Status <br />Transfer to <br />New Owner? <br />(Circle One) <br />Active/I nactve <br />Delete <br />4244 - PUMPER TRUCK PR0543484 EE0000039 -AARON GOODERHAM Y 101 A <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 facilit <br />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 Ordinance Codes and/or Standards and State and/or <br />Federal Laws s-c <br />-2.-t> 1/4 cb • <br />(Alfi 77(s7 -/ <br />k/ps c7 frawv, f/voI `-`•