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----------- <br /> g' <br /> Dale run 2113/2014 11:36:43AI SAN JG UIN COUNTY ENVMONMENTAL HEA;. .1 DEPARTMENT Report#5021 <br /> Paget <br /> R.by Facility Information as of 2/13/2014 <br /> Record Selection Criteria: Facility 10 FA0017211 <br /> Make changes/corrections In RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax lD <br /> Owner ID OW0014052 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 -V>C) WX 2-2.1s, <br /> Mailing Address t8636-E­MfET-et+-RD <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0017211 10,186,085 <br /> Facility Name COOPER OUT WEST <br /> Location 11797 MILTON RD <br /> LINDEN, CA 95236 <br /> Phone 209-467-1324 xO <br /> Mailing Address 18686 E M16TE)N RD <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 10512004 Ell <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030093 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner I Facility Account <br /> Account Name COOPER OUT WEST (Circle One) <br /> Account Balance as of 2113/2014: $53.00 <br /> (Circle One) <br /> Transfer to Acd.nneMe <br /> Program/Element and Description Record 10 Employee 10 and Name Status New Owna? Delete <br /> 1958-HM-Farm Operations PRO525396 Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PRO530184 EE0009488-JEFFREY WONG Activej Y IN A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533761 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACIKNOWLEDGEMENT. 1,the undersigned owrier,operator or agent of same,acknowledge that all site,anclor project specific,PHSIEFID hourly charges associated with this faality <br /> or'divity will be billed to the party identified as Me OWNER an this form. I also carfiffy that all operations will be performed in accordance with all applicable Ordinance Codes andi Standards and State anclo, <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: $25.00 is Amount Paid_ Date <br /> Water System to be TRANSFERED: Amount Paid -- Date <br /> Payment Type Check Number --Rece. <br /> RENS: Date Account out: Date <br /> COMMENTS: <br />