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Date run 8/14/2014 1:25:15PK SAN JOI,,ll,,,rtJIN COUNTY ENVIRONMENTAL HEA11/DEPARTMENT Repod#5021 <br /> Run byPagel <br /> Facility Information as of 8/1412014 <br /> Record Selection Criteria: Facility ID FA0022499 <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 OW0020004 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 ID/CERS ID FA0022499 10415419 <br /> Facility Name AT&T Mobility- LINDEN (9858) <br /> Location 5252 N ESCALON BELLOTA RD <br /> LINDEN, CA 95236 <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 <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 AR0041178 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AT&T Mobility- LINDEN (9858) (Circle One) <br /> Account Balance as of 8/14/2014: $0.00 <br /> (Circle One) <br /> Transferto Activelmactve <br /> PrograMElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PRO539353 EE0008709-JAMIE DE LA ROSA 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 project specific,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also codify that all operations will be performed in accordance with all applicable Ordinance Codes sector Standards and State ands <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 / I <br /> Payment Type ��Check Number Receiily <br /> REHS: W 1J Date W / l Account out: Date <br /> COMMENTS: <br /> cpm IV�`^ -2 tsb'R-A-w- vk <br />