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Date run 2!1312014 11:37:12AI SAN J DIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> 7�un by *.MOOF Pagel <br /> Facility Information as of 2/13/2014 <br /> Record Selection Criteria: Facility ID FA0017214 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014055 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 /> 12:0AMailing Address <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0017214 10,186,091 <br /> Facility Name COOPER OUT WEST <br /> Location 976 DUNCAN RD <br /> LINDEN, CA 95236 <br /> Phone 209-467-1324 x0 <br /> Mailing Address PO —e�oc <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 10512006 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 AR0030096 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility I Account <br /> Account Name COOPER OUT WEST (Circle One) <br /> Account Balance as of 2/13/2014: $53.00 <br /> (Circle One) <br /> Transfer to ActivelEnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525399 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO530566 EE0000753-WILLY NG Active,! Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532858 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that ail site,andrar project specific,PHSIEHD 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 and'or Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 / <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid D e 1 I <br /> Payment Type Check Number Receiv! <br /> REHS: Date / ! Account out: Date 1 1 <br /> COMMENTS: <br />