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Report#5021 <br /> Da a mn 2/13/2014 11:39:29A1 SAN Jl7�UIN COUNTY ENVIRONMENTAL HEAT DEPARTMENT pages <br /> R°"by Facility Information as of 2/13/2014 <br /> Record Selection Criteria: Facility ID FA0005082 <br /> Make changeslcorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI Fed Tax ID <br /> Owner ID OW0003962 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 ,l-8$36-E-MtEzFE44-R0 lex 2 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERSID FA0005082 10,181,727 <br /> Facility Name COOPER OUT WEST <br /> Location 29756 E ORANGE AVE <br /> ESCALON, CA 95320 <br /> Phone 209-467-1324 xO <br /> Mailing Address q-8636-E-jVffUE 4-R$ <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code 06 - ESCALON Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 24919005 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0005527 New Account ID: <br /> Mail lnvoicesto Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name COOPER OUT WEST (01"One) <br /> Account Balance as of 2/1312014: $53.00 <br /> (Circle One) <br /> Transfer to ActivelmacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owne!! Delete <br /> 1958-HM-Faun Operations PRO525911 Active Y N A I D <br /> 2333-FARM UST#1 FACILITY-obsolete PR0501371 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO529937 EE0000753-WILLY NG Aclive,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533693 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acunowledge that all site,and/or pmjeet spec,PHSIEHO hourly charges associated with this facility <br /> or activity will W billed to the party identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ander <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 Re i by r <br /> REHS: Date_I Account out: Date '7— / / <br /> COMMENTS: <br />