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Date run 4/6/2016 3:41:36PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 4/6/2016 <br />Record Selection Criteria: Facility ID FA0022553 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION <br />Number of facilities for this owner: 1 SSN/Fed Tax ID <br />Owner ID <br />OW0020111 New Owner ID <br />Owner Name <br />New Cingular Wireless PCS, LLC dba AT&T N <br />Owner DBA <br />Owner Address <br />308 S AKARD ST 1708 <br />DALLAS, TX 75202 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />214-464-2626 <br />Mailing Address <br />308 S AKARD ST RM 1708 <br />DALLAS, TX 75202 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022553 10479937 <br />Facility Name <br />AT&T Mobility - HWY 88 - EAST FAIRCHILD f <br />Location <br />6844 E FAIRCHILD RD <br />Stockton, CA 95215 <br />Phone <br />800-638-2822 x <br />Mailing Address <br />308 S Akard St Rm 1708 <br />Dallas, TX 75202 <br />Care of <br />AT&T Mobility <br />Location Code <br />Alt Phone <br />BOS District <br />Fax <br />APN <br />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 <br />AR0041245 New Account ID: <br />Mail Invoices to <br />Account Mail Invoices to: Owner / Facility / Account <br />Account Name <br />AT&T Mobility Manager EH&S EPCRA (Circle One) <br />Account Balance as of 4/6/2016: <br />$0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description <br />Record ID Employee ID and Name Status New Owner? te <br />61D <br />1926 - HMBP-Unstaffed Network Location PR0539448 EE0000009 - NICHOLAS LOEHRER Active,l Y N AD <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility <br />or activity will 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 and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Ty <br />Check Number Receiv <br />EHD Staff: �V\A 0A.— <br />/. <br />Date / / Account out: Zh4 Date /--Ca/ <br />COMMENTS: <br />Invoice #: <br />CA.IM► <br />bt[k) r-pVbX'bU �, <br />