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__. __ _ _ _ _ _____ ___ ......... ____ ------- <br /> Date win <br /> ______Datewn 2/13/2014 11:37:51AI SAN JC""'IUIN COUNTY ENVIRONMENTAL HE ' DEPARTMENT Repod%5021 <br /> Ranby Pagel <br /> Facility Information as of 2/13/2014 <br /> Record Selection Criers: Facility ID FA0017215 <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 OW0014056 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 lD/CERS ID FA0017215 10,186,093 <br /> Facility Name COOPER OUT WEST <br /> Location 11711 E EIGHT MILE RD <br /> STOCKTON, CA 95212 <br /> Phone 209-467-1324 x0 <br /> Mailing Address ^}� —kl-bX <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 06312004 EMaii: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030097 New Account to: <br /> Mail lnvoicesto Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name COOPER OUT WEST (Circle one) <br /> Account Balance as of 2/13/2014: $266.00 <br /> (Circle One) <br /> Transferto ActivoinscNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525400 Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO530389 EE0001422-ARTS CACAPIT Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530388 EE0001422-ARTS CACAPIT Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534036 Inactivr Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSfil 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 endor Standards and State ancior <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 Receiv I/ <br /> REHS: Date / / Account out: FV Date <br /> COMMENTS: "-/7— <br />