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Date run 2/27/2013 11:32:39AI SAN JI WIN COUNTY ENVIRONMENTAL HEi A DEPARTMENT Report #5021 <br />Run by - Pagel <br />Facility Information as of 2/27/2013 <br />Record Selection Criteria: Facility ID FA0003366 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION SSN / Fed Tax ID <br />Owner ID OW0002492 Case Number: 002443 New Owner ID <br />Owner Name BADER DAIRY E2 t— S' <br />Owner DBA BADER DAIRY <br />Owner Address 23628 E MARIPOSA RD <br />ESCALON, CA 95320 <br />Home Phone 209-499-7475 <br />Work/Business Phone Not Specified <br />Mailing Address PO BOX 825 <br />TWAIN HARTE, CA 953830825 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID FA0003366 <br />Facility Name BADER DAIRY <br />Location 23662 E MARIPOSA RD <br />ESCALON, CA 95320 <br />Phone 209-499-7475 <br />Mailing Address PO BOX 825 <br />TWAIN HARTE, CA 953830825 <br />Care of BADER FARMS <br />Location Code 99 - UNINCORPORATED P Alt Phone <br />BOS District 004 - VOGEL, KEN Fax <br />APN 20717009 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 AR0002943 New Account ID: <br />Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br />Account Name BADER DAIRY (Circle One) <br />Account Balance as of 2/27/2013: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0525886 Active Y N A I D <br />48TONS/YR, <br />0 - GRADE A DAIRY PR0200056 EE0004589 - KADEANNE LINHARES Inactive Y N A I D <br />220 SM HW GEN <5 PR0529339 EE0002670 - MUNIAPPA NAIDU Active Y N A I D <br />AST FAC - SPCC EXEMPT PRO529317 EE0002670 - MUNIAPPA NAIDU Active,Exempt Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHiPR0532936 Inactive 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, PHS/EHD hourly charges associated with this facility <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 />j ederal Law y —bo gap—) <br />APPLICANT'S 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 Ch k Number RV by <br />REHS: _pate o2 /a7 /� Account out: Date <br />COMMENTS: � 1q� <br />1 v <br />