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Date run 61112015 3:46:50PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/1/2015 <br /> Record Selection Critena. Facility ID FA0022965 <br /> Make changestcorrections 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 OW0020987 New Owner ID <br /> Owner Name AMERICAN TOWERS <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 602-284-0280 <br /> Mailing Address P.Q. BOX 63604 <br /> PHOENIX, AZ 85082 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022965 10630189 _ <br /> Facility Name AMERICAN TOWERS- LOCKEFORD CA- S11 <br /> Location 14700 E State Rte 88 <br /> Lockeford, CA 95237 <br /> Phone 602-284-0280 x <br /> Mailing Address P.O. BOX 63604 <br /> PHOENIX, AZ 85082 <br /> Care of AMERICAN TOWERS- LOCKEFORD CA- S11 <br /> Location Code Alt Phone <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 AR0042123 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility f Account <br /> Account Name AMERICAN TOWERS- LOCKEFORD CA- SITE#83( (Circle One) <br /> Account Balance as of 61112015: $0.00 <br /> (Circle One) <br /> Transfer to Activelinaetve <br /> P m! lement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1 HMBP-Common Materials PRO540168 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ® G and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEHD hourly charges associated with this facility or; <br /> 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 and/or Standards and State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / ! <br /> Program Records to be TRANSFERED: 'S25.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Type Check Number Received b�y��y, <br /> EHD Staff: Date_ (o! L / t Account out: Date <br /> COMMENTS: <br /> Invoice#: <br /> AtA <br /> t 5 A� t 5 tl Ivt',, V C A-,2-c71� FRC t 1' rA-r S lirvhE <br /> A-DDcs. <br />