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vvv._�i-_uuvavg4]vv'• s iv- vi-.ivviuv s.vv :viuu�:vivvssivvv-:�v�� vnvuuiivuvvr........... <br /> Date run4)13@014 11:41:1 BAI SANK JC�UIN COUNTY ENVIRONMENTAL HEA T DEPARTMENT Repo #5021 <br /> Run by Pagel <br /> Facility Information as of 2/13/2014 <br /> Record Selection Cnteda: Facility ID FA0017389 <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 OW0014230 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 +8636-E-­M­I­hzF0"D T'D ^]�:DX, 2.2.(0 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017389 10,186,377 <br /> Facility Name COOPER OUT WEST <br /> Location 30783 RIVER RD <br /> ESCALON, CA 95320 <br /> Phone 209-467-1324 xO <br /> Mailing Address +8&3 T-erhJ- D p0 160K 2Z(o <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 24915010 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 AR0030271 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name COOPER OUT WEST (Clyde One) <br /> Account Balance as of 2/13/2014: $53.00 <br /> (Circle One) <br /> Transfer to Activellnactue <br /> PrograMElemenl and Description Record ID Employee ID and Name Status New Omen Delete <br /> 1958-HM-Fane Operations PRO525574 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO529810 EE0000753-WILLY NG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533879 Inactive 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,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identi ied as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 Racal 7 <br /> REHS: Date Il Account out: Date 1 / <br /> COMMENTS: <br />