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Daterun 8/14/2014 1:47:18PR SAN J IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Repoli 5021 <br /> Paget <br /> Run by <br /> Facility Information as of 8/14/2014 <br /> Record Selection Criteria: Facility ID FA0022504 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSNIFed Tax ID : <br /> Owner ID OW0020014 New Owner ID <br /> Owner Name New Cingular Wireless PCS, LLC dba AT&T N <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 925-823-8954 <br /> Mailing Address PO BOX 5095, ROOM 3E000 <br /> SAN RAMON, CA 94583 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022504 10415701 <br /> Facility Name AT&T Mobility-BEN HOLT(35516) <br /> Location 6844 Alexandria PI <br /> Stockton, CA 95207 <br /> Phone 800-638-2822 x <br /> Mailing Address PO BOX 5095, ROOM 3E000 <br /> SAN RAMON, CA 94583 <br /> Care of AT&T Mobility Alt Phone <br /> Location Code <br /> BOS District Fax <br /> APN 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 AR0041183 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AT&T Mobility-BEN HOLT (35516) (Circle One) <br /> Account Balance as of 8/14/2014: $0.00 (Circle One) <br /> Transfer to Aclivennadve <br /> PrograMElement and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0539358 EE0000006-HAZA SAEED Active,l Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor protea 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 endor Standards and State ander <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 Date <br /> Payment Type Check Number Date Account Receiv <br /> te / <br /> / t� / l Ant out: Da <br /> RENS: / <br /> COMMENTS: <br /> C <br /> "�� (I;-viii VSA- . <br />