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Date run V .4,4;015 11:19:51AM SAN X UIN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 4/8/2015 <br />Record Selection Criteria: Facility ID FA0022732 <br />OWNER FILE INFORMATION Number of facilities for this owner: <br />Owner ID OW0020486 <br />Owner Name T -MOBILE WEST CORPORATION <br />Owner DBA <br />Owner Address <br />12920 SE 38TH ST <br />BELLEVUE, WA 98006 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />425-383-4000 <br />Mailing Address <br />12920 SE 38th Street <br />Bellevue, WA 98006 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0022732 10609624 <br />Facility Name METRO -PCS SAC134 <br />Location 16717 W GRANT LINE RD <br />Tracy, CA 95391 <br />Phone 888-662-4662 x <br />Mailing Address 1755 Creekside Oaks Dr., Suite 190 <br />Sacramento, CA 95833 <br />Care of T -MOBILE WEST CORPORATION <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0041642 <br />Mail Invoices to Account <br />Account Name Michelle Steffler <br />Account Balance as of 4/8/2015: $332.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />EE0002474 - MICHAEL PARISSI Active Y N A 0 D <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: l ,/ l l Date�/ u /� <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date / / <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Typ Check Number Received by <br />REHS: Pyr Lti Date '-A Account out: Date /,moo 115 - <br />COMMENTS: <br />��ke--1� ✓k-7� <br />