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Date ren 12/512013 9:50:35AR SAN JOA( NCOUNTYENVIRONMENTALHEALT' EPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 12/5/2013 f Pagel <br /> Rewfd Selection Criteria: Facility ID FA0019363 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008734 New Owner ID <br /> Owner Name VERIZON WIRELESS INC <br /> Owner DBA <br /> Owner Address 255 PARKSHORE DR <br /> FOLSOM, CA 95630 <br /> Home Phone 866-694-2415 <br /> Work/Business Phone Not Specified <br /> Mailing Address 255 PARKSHORE DR <br /> FOLSOM, CA 95630 <br /> Care of VERIZON WIRELESS <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019363 10144769 <br /> Facility Name VERIZON WIRELESS)(QUAIL LAKE <br /> Location 2323 GRAND CANAL BLVD <br /> STOCKTON, CA 95207 <br /> Phone 9600 <br /> Mailing Address27ORz'q- AR)e U)F= Z <br /> 598 so Gut 1;�la 30 <br /> Care of VERIZON WIRELESS INC <br /> Location Code (g I Alt Phone <br /> BOIS District 00 7- Fax <br /> APN 11011007 s C G e i // <br /> �1 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 AR0034403 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VERIZON WIRELESS-QUAIL LAKES (Circle One) <br /> Account Balance as of 12/5/2013: $0.00 <br /> (circle One) <br /> Transferto Active/Inadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528898 EE0004636-GARRETT BACKUS 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 protect specific,PHSiEHD hourly charges associated with this faulity <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 endor Standards and State ander <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 <br /> Payment T}�e Check Number � Receiv �L� <br /> REHS: I�_ �l OTJ �� Date ,_/�/ Account out: Date <br /> COMMENTS: <br />