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Date run 2/2/2015 3:18:09PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5027 <br /> Run by Pagel <br /> Facility Information as of 2/2/2015 <br /> Record Selection Criteria: Facility ID FA0022774 <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 OW0020610 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, RM 4W200 <br /> SAN RAMON, CA 94583 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022774 10613365 <br /> Facility Name AT&T Mobility- HWY 132-S BIRD ROAD (474 <br /> Location 33856 S Bevis Rd <br /> Tracy, CA 95304 <br /> Phone 800-638-2822 x <br /> Mailing Address PO BOX 5095, RM 4W200 <br /> SAN RAMON, CA 94583 <br /> Care of AT&T Mobility <br /> Location Code Alt Phone <br /> BOIS 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 AR0041739 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Manager EH&SEPCRA (Circle One) <br /> Account Balance as of 2/2/2015: $0.00 <br /> (Circle One) <br /> Transfer to ActiveAni <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO539814 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,arknowiedge that all site,ander project speck,PHS/EHD hourly charges associated with this facility <br /> or activity will be billetl 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 andor Standards and State ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type T Check Number Received b <br /> REHS: Wn/ Date L!5_ Account out: Date_/ <br /> COMMENTS: <br /> 't✓t1*rF�fc0 N6%J V=ij t'1""1 + P"(-AA's ul 4 L 5 <br /> 1�Jo - <br />