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Date run 2/13/2014 11:36:43AI SAN JC UIN COUNTY ENVIRONMENTAL HEA 1 DEPARTMENT Report#5021 <br /> Run Ly Pagel <br /> Facility Information as of 2/13/2014 <br /> Record Selection Criteria: Facility ID FA0017211 <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 OW0014052 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 p0 —BOX ZZ� <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017211 10,186,085 <br /> Facility Name COOPER OUT WEST <br /> Location 11797 MILTON RD <br /> LINDEN, CA 95236 <br /> Phone 209-467-1324 x0 <br /> Mailing Address 18636 E MIL4eN 3>Q <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 10512004 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 AR0030093 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 /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525396 Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530184 EE0009488-JEFFREY WONG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533761 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 anrYor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid D e <br /> Payment Type Check Number Recei ,�,, <br /> REHS: Date / / Account out: Date /�(07N <br /> COMMENTS: <br />