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Date nm '2/19/2014 10:22:55AI SAN JC JIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT Repos a5021 <br /> Paget <br /> Run by <br /> Facility Information as of 2/19/2014 <br /> Record Selection Criteria: Facility ID FA0017402 <br /> Make changesicorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014243 New Owner ID <br /> Owner Name CHARLES S COX FARMS <br /> Owner DBA CHARLES S COX FARMS <br /> Owner Address 0 HWY 33 AT HWY 132 <br /> VERNALIS, CA 95385 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1381 <br /> PATTERSON, CA 95363 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017402 10,186,399 <br /> Facility Name CHARLES S COX FARMS <br /> Location 0 HWY 33 AT HWY 132 <br /> VERNALIS, CA 95385 <br /> Phone 209-894-3741 x0 <br /> Mailing Address PO BOX 1381 <br /> PATTERSON, CA 95363 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 25519001 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 AR0030284 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name CHARL OX FAR r V(� % n (Circle One) <br /> Account Balance as of 2/19/2014 d /G(J� <br /> ��// (Circe One) <br /> Transfer to Aclive/Inactye <br /> Program/Element and Description Record ID Employee ID and Name Status New 0.0 Delete <br /> 1958-HM-Farm Operations PRO625587 Active Y N AI D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO530992 EE0000753-WILLY NG Active,l Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533305 Inactive Y N A D <br /> BILLING ark COMPLIANCE ACKNOWLEDGEMENT: I,the und.rsi,nedl owner,operator or agent of same,acknowledge that all site,anNor Project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER an this fano. I also certify that all operations will be performed In accordance with all applicable Ordinance Codea anti Standards and State andfor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water Systemtobe TRANSFERED: Amount Paid Date /_/ <br /> Paymenty r M het-ck Number Date / / Account out: Receiv d Y Date / /� <br /> REHS: ' /��1 J— IF'�� <br /> ZZ <br /> COMMENTS: e <br /> �ruJoi� <br />