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I k;;K- <br /> Date run 2/13/2014 11:37:12A] SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Ron by Pagel <br /> Facility Information as of 2/13/2014 <br /> Record Selection,Criteria: Facility to FA0017214 <br /> Make changes/corrections In RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0014055 New Owner ID <br /> Owner Name COOPER OUT WEST <br /> Owner DBA COOPER OUT WEST <br /> Owner Address 18636 E MILTON RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017214 10,186,091 <br /> Facility Name COOPER OUT WEST <br /> Location 976 DUNCAN RD <br /> LINDEN, CA 95236 <br /> Phone 209-467-1324 xO <br /> Mailing Address 16636 E MILTON RE) _P0 -R)O)C <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 10512006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Amount 10 AR0030096 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner IF Facility Account <br /> Account Name COOPER OUT WEST (Circle One) <br /> Account Balance as of 2/13/2014: $53.00 <br /> (Circle One) <br /> Transfer Is Acifinsfifiniscon, <br /> Program/Element and Description Record ID Employee ID and Name Stews New Owner? Ddeds <br /> 1958-HM-Farm Operations PRO525399 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO530566 EE0000753-WILLY NG Activej Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532858 Inactive Y IN A I D <br /> BILLING and COMPLMCE ACI(NOWI_EDGEMENT:. 1,the undersigned owner,operator or agent of same,acknowledge Net all site,andror project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as Me OWNER on this form, I also cernify that all operations be performed in accordance with all applicable Ordinance Codes andor Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: $25.00= Amount Paid- Date I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receiv <br /> REHS: Date I Account out Date <br /> COMMENTS: <br />