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Date run x 2/13/2014 11:41:18AI SAN JCtUIN COUNTY ENVIRONMENTAL HEA,�I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/13/2014 <br /> Record Selection Criteria: Facility ID FA0017389 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 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 18636 E M I bTeN RDX. 22(o <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FAb017389 10,186,377 <br /> Facility Name COOPER OUT WEST <br /> Location 30783 RIVER RD <br /> ESCALON, CA 95320 <br /> Phone 209-467-1324 x0 <br /> Mailing Address <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 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name COOPER OUT WEST (Circle One) <br /> Account Balance as of 2/13/2014: $53.00 <br /> (Circle One) <br /> Transferto Activennactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525574 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0529810 EE0000753-WILLY NG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533879 Enactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,eperator or agent of same,acknowledge that all site,andfor project specific,Pi hourly charges associated with this facii <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 andfor Standards antl State andlor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid to 1 1 <br /> Payment Type Check Number Recei <br /> RENS: Date ! / Account out: t� Date 1 / )a <br /> COMMENTS: <br />