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Date run 8/11/2017 2:05:26Ph1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 8/11/2017 <br /> Record Selection Criteria: Facility ID FA0021380 <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: 17 SSN I Fed Tax ID <br /> Owner ID OW0016711 New Owner ID <br /> Owner Name T-MOBILE WEST CORPORATION <br /> Owner DBA METRO PCS SAC <br /> Owner Address 12920 SE 38th ST <br /> BELLEVUE, WA 98006 <br /> Home Phone 888-313-0188 <br /> Work/Business Phone 425-383-4000 <br /> Mailing Address 12920 SE 38th Street <br /> Bellevue, WA 98006 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0021380 10187841 <br /> Facility Name METRO PCS SAC-442 <br /> Location 16001 GLASSCOCK RD <br /> LODI, CA 95242 <br /> Phone 888-313-0188 x <br /> Mailing Address 7851 ORCHARD DR SUITE 200 <br /> FOLSOM, CA 95630 <br /> Care of METROPC CA, LLC SAC442 <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 02502012 Ell <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 888-313-0188 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0038745 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name METRO PCS SAC-442 (Circle One) <br /> Account Balance as of 811112017: $0.00 <br /> (Circle One) <br /> Transfer to Activehractve <br /> Program/Element and Description Record ID Employee ID and Name Status New nwnpr7 Delete <br /> 1920-HMBP-Common Materials PRO537253 EE0008709-JAMIE LIMA Active Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSJEHD hourly charges associated with this <br /> facility 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 andlor Standards <br /> and State andfor Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date f I <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Received <br /> EHD Staff: �� Date III 1� bye Account out: Date 1 1 <br /> COMMENTS: <br /> Invoice#: <br />