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Date run 9/28/2016 3:30:50Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 9/28/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0023674 <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 OW0021990 New Owner ID <br /> Owner Name VeriZ0n Wireless <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 866-694-2415 <br /> Mailing Address 295 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023674 10687891 <br /> Facility Name Verizon Wireless Tracy USD <br /> Location 26101 S Corral Hollow Rd <br /> Tracy, CA 95376 <br /> Phone 866-694-2415 x <br /> Mailing Address 295 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of Verizon Wireless <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 240-100-06 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 AR0043790 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility 1 Account <br /> Account Name Environmental Compliance (Circle one) <br /> Account Balance as of 9128/2016: $0.00 <br /> (Circle One) <br /> Program/Element and Description Transfer to Activellnactve <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO541317 EE0000010-PETER LOMBARDI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity wiil be billed to the party identified as the OWNER on this Torn. I also cortify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State andlor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date / 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date (571 219 ^{moo lL-Account out: Date 1 A <br /> COMMENTS: <br /> Invoice#; <br /> y r� i r,�, l NP�w Sc c�w�.iss►ah- des �0 <br />