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Date run 1/20/2012 2:20:07PR SAN JUIN COUNTY ENVIRONMENTAL HEAOR DEPARTMENT Report #5021 <br />Run by 5290 Pagel <br />Facility Information as of 1/20/2 <br />Record Selection Criteria: Facility ID FA0010772 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0008772 Case Number: H08700 <br />Owner Name <br />DAN MILLS <br />Owner DBA <br />COPE MFG CO <br />Owner Address <br />20400 N KENNEFICK RD <br />Y N <br />ACAMPO, CA 95220 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-334-1999 <br />Mailing Address <br />PO BOX 2660 <br />I D <br />LODI, CA 952412660 <br />Care of <br />Active <br />FACILITY FILE INFORMATION <br />A <br />Facility ID <br />FA0010772 <br />Facility Name <br />COPE MFG CO <br />Location <br />20400 N KENNEFICK RD <br />I D <br />ACAMPO, CA 95220 <br />Phone <br />209-334-1999 x0 <br />Mailing Address <br />PO BOX 2660 <br />I D <br />LODI, CA 952412660 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />BOS District 004 - VOGEL, KEN <br />APN 01714042 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name DAN MILLS <br />Title OWNER <br />Day Phone 209-334-1999 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0017772 <br />Mail Invoices to Owner <br />Account Name DAN MILLS <br />Account Balance as of 1/20/2012: $362.50 <br />Make changes/corrections in RED Ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New wnerID <br />/ I,- <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />Program/Element and Description Record ID <br />Em to ee ID antl Name <br />P Y <br />Slalus <br />Transfer to <br />New Owner? <br />(Circle One) <br />Activellnactve <br />Delete <br />2220 - SM HW GEN <5 TONS/YR PRO535540 <br />EE0001422 - ARIS CACAPIT <br />Active <br />Y N <br />A <br />I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513060 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y N <br />A <br />I D <br />2244 -PACT TRANSFER RECORD - DES PR0520482 <br />EE0000000-HAZ MAT SJC DES <br />Active <br />Y N <br />A <br />I D <br />2333 - FARM UST #1 FACILITY - obsolete PR0501162 <br />EE0004636 - GARRETT BACKUS <br />Inactive <br />Y N <br />A <br />I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARIPRO510772 <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />Y N <br />A <br />I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPRO531312 <br />Active <br />Y N <br />A <br />I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site, and/or <br />project specific, PHS/EHD <br />hourly charges associated with this <br />facility or activity will be billed to the party Identified as the OWNER on this form. I also cerlHy that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br />State ands Federal Laws. <br />APPLICANTS SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: • $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received <br />REHS: Date / I Account out: Date �_/� <br />COMMENTS: rhe h A A! / �/ 12' / <br />\\eh-env\envision\reports\5021.rpt II/'L lVL t/f e , LT l/�aU �1a'�-(/�U�. v{'t,(�i1.v��U/✓, V./�C /",iyJ `�_., <br />