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Date run 1/1412015 4:12:48PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1114/2015 <br /> Record Selection Criteria Facility ID FA0022740 <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 SSN/Fed Tax ID <br /> Owner ID OW0020522 New Owner ID <br /> Owner Name Verizon Wireless <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 866-694-2435 <br /> Mailing Address 255 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0022740 10600879 <br /> Facility Name Verizon Wireless Hwy 5 at 4 <br /> Location 15 & West Anderson St <br /> Stockton, CA 95206 <br /> Phone 866-694-2415 x <br /> Mailing Address 255 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of Verizon Wireless <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 163-260-25 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> T6tle <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041681 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Environmental Compliance (Circle one) <br /> Account Balance as of 1/14/2015'. $0.00 <br /> (Gircle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Warne Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO539751 EE0009817-ROBERT LOPEZ Active 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,PHSlEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER.on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / ! <br /> Water System to be TRANSFFRFD Amount Paid Date / f <br /> Payment Type Check Number Received b <br /> REH5: kkA Date ! { 1L _ Account out: Date ! 11 <br /> COM�MEnNTT,S.,: �+rr <br /> cfi '`� oil L�1.1{1'� X10-�KV� VO,, Ce+`--S . <br />