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Date run 2/13/2014 11:37:51AI SAN JC IUIN COUNTY ENVIRONMENTAL HEA 1 DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/13/2014 <br />Record Selection Criteria: Facility ID FA0017215 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0014056 <br />Owner Name <br />COOPER OUT WEST <br />Owner DBA <br />COOPER OUT WEST <br />Owner Address <br />18636 E MILTON RD <br />=1-8636-E-MII✓TON-RD <br />LINDEN, CA 95236 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />1-8636-E-MIL—TflN-RD-- <br />LINDEN, CA 95236 <br />Care of <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017215 10,186,093 <br />Facility Name <br />COOPER OUT WEST <br />Location <br />11711 E EIGHT MILE RD <br />STOCKTON, CA 95212 <br />Phone <br />209-467-1324 x0 <br />Mailing Address <br />=1-8636-E-MII✓TON-RD <br />LINDEN, CA 95236 <br />Care of <br />Location Code <br />BOS District <br />APN <br />06312004 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030097 <br />Mail Invoices to Owner <br />Account Name COOPER OUT WEST <br />Account Balance as of 2/13/2014: $266.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />l- 0 -i6b>C <br />T'lo -tlb?e' 22� <br />Alt Phone <br />Fax <br />EMail: <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0525400 Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0530389 EE0001422 - ARIS CACAPIT Active Y N A I D <br />2830 - AST FAC - SPCC EXEMPT PRO530388 EE0001422 - ARIS CACAPIT Active,I Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534036 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and(or project specific, PHS/EHD 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 andror Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />Date / /- <br />* $25.00 = Amount Paid Date <br />Amount Paid Date <br />Date / <br />Recelv d �l <br />Account out: Date .q/ / <br />