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ESeleclior <br /> !2014 8:55:45A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMLNT <br /> Repan#5021 <br /> Facility Information as of 10/23/2014 Pagel <br /> Clia: Facility ID FA0022636 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0020228 New Owner ID <br /> Owner Name Sprint <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Works/Business Phone 877-347-4457 <br /> Mailing Address P O BOX 7994 <br /> SHAWNEE MISSION, KS 66207 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID!CERS ID FA0022636 10589944 <br /> Facility Name Sprint Cell Site SF04UB086 <br /> Location 1624 E HAMMER LN <br /> Stockton, CA 95203 <br /> Phone $77-347-4457 x4 <br /> Mailing Address P.O. Box 7994 <br /> Shawnee Mission, KS 66207 <br /> Care of Sprint <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account kD AR0041435 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner ! Facility ! Account <br /> Account Name Sprint Cell Site SF04UB086 (Circle One) <br /> Account Balance as of 1012312014: 50.00 <br /> (Circle One) <br /> ProgramfElement and DescriptionRecord ID Employee ID and Name Status Transfer to Active4 ive <br /> New Owner? Delete <br /> 1921 -HMBP-Requiar-Primary Location PR0539562 EE0000006-HAZA SAEED Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSlEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forrR I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ancilor Standards and Slate and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date l / <br /> Program Records to be TRANSFERED- "$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Rece v y <br /> REHS: Date LO ! r?- 7> f l�� ._ Account out: �_ Date ! l <br /> COMMENTS: <br /> (3k w t C-H-e-v ,\ Ili V4 a; 7p)qI <br />