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Date run 8/17/2010 3:14:00PA SAN JUIN COUNTY ENVIRONMENTAL HEA# DEPARTMENT Report #5021 Run by Facility Information as of 8/17/2Pagel 0 nacora seiecuon cnteria: Facility ID FA0010772 OWNER FILE INFORMATION Owner ID OW0008772 Case Number: H08700 Owner Name DAN MILLS Omer DBA DBA COPE MFG CO Owner Address 20400 N KENNEFICK RD 209-334-1999 x0 ACAMPO, CA 95220 Home Phone Not Specified Work/Business Phone 209-334-1999 Mailing Address PO BOX 2660 LODI, CA 952412660 Care of FACILITY FILE INFORMATION Facility ID FA0010772 Facility Name COPE MFG CO Location 20400 N KENNEFICK RD Facility / ACAMPO, CA 95220 Phone 209-334-1999 x0 Mailing Address PO BOX 2660 Account Balance as of 8/17/2010: $362.50 LODI, CA 952412660 Care of Location Code 99 - UNINCORPORATED A BOS District 004 - VOGEL, KEN APN 017-140-42-7 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : L(.S 77 3 AeA& -401 i Account ID AR0017772 New Account ID: : Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account Account Name DAN M ILLS &-k+WE-VAL0.EZ. (Circle) Account Balance as of 8/17/2010: $362.50 (Circle One) Transfer to Active/Inactva Program/Element and Description Record ID Employee In and Name Status New Owner? Delete 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513060 EE0000000 - HAZ MAT SJC DES Inactive Y N A I D 2244 - PACT TRANSFER RECORD - DES PRO520482 EE0000000 - HAZ MAT SJC DES Active Y N A I D 2333 - FARM UST #1 FACILITY - obsolete PRO501162 EE0004636 - GARRETT BACKUS Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARPRO510772 EE0000000 - HAZ MAT SJC DES Inactive Y N A I D ERSC - ELECTRONIC REPORTING SURCHARGE PRO531312 Active Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknoWedge that all site, and/or project specific, PHS/EHD hourly charges associated wdh this facility 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 Ordinace Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: . $20.00 = Water System to be TRANSFERED: ' $372.00 = _ Payment Typei� Check Number REHS: �T`� Date_ COMMENTS: \\eh-env\envision\reports\5021.rpt Date _ Amount Paid Date Amount Paid Date Received by Account out: Date