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RECEIVED <br />UNIDOCS <br />FACILITY INFORMATION <br />BUSINESS OWNER/OPERATOR IDENTIFICATION PAGE,- SANJOAQUINC <br />Page of <br />L IDENTIFICATION <br />FACILITY ID # <br />1. <br />BEGINNING DATE 100 <br />ENDING DATE 101. <br />(Agency Use Only) <br />H <br />- <br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. <br />BUSINESS PHONE 102. <br />T -MOBILE WEST CORPORATION SITE ID#SC07014A <br />UNMANNED FACILITY <br />BUSINESS SITE ADDRESS 103. <br />BUSINESS FAX 102x, <br />1610 ISHI GOTO STREET <br />UNMANNED FACILITY <br />BUSINESS SITE CITY ° <br />ZIP CODE 105. <br />COUNTY 108. <br />STOCKTON <br />CA <br />95206 <br />SAN JOAQUIN <br />DUN & BRADSTREET 106. <br />06-632-8376 <br />PRIMARY SIC 107 <br />PRIMARY NAICS <br />4812 <br />517212 <br />BUSINESS MAILING ADDRESS 1014., <br />1755 CREEKSIDE OAKS, SUITE 190 <br />BUSINESS MAILING CITY 1'81 <br />STATE: toss. <br />ZIP CODE toad. <br />SACRAMENTO <br />CA <br />1 <br />95833 <br />BUSINESS OPERATOR NAME 109. <br />BUSINESS OPERATOR PHONE 110. <br />T -MOBILE WEST CORPORATION <br />(425)383-4000 <br />II. BUSINESS OWNER <br />OWNERNAME T -MOBILE WEST CORPORATION 111' <br />OWNERPHONE 112. <br />(425) 383-4000 <br />OWNER MAILING ADDRESS 113. <br />12920 SE 38TH STREET <br />OWNER MAILING CITY ; <br />STATE 115. <br />ZIP CODE 116. <br />BELLEVUE <br />WA <br />98006 <br />I1I. ENVIRONMENTAL CONTACT <br />CONTACT NAME 117. <br />CONTACT PHONE 118. <br />MICHELLE STEFFLER <br />(916)643-8979 <br />CONTACT MAILING ADDRESS 119. <br />CONTACT EMAIL 119 <br />1755 CREEKSIDE OAKS, SUITE 190 <br />CONTACT MAILING CITY SACRAMENTO 120. <br />ATE 121. <br />STCA <br />ZIP CODE 122 <br />95833 <br />-PRIMARY- IV. EMERGENCY <br />CONTACTS -SECONDARY- <br />NAME 123. <br />NAME 128. <br />NICHOLAS H. FISCHER <br />T -MOBILE WEST NOCC <br />TITL£ tza. <br />TITLE t'-9. <br />MANAGER- ENGINEERING <br />N/A <br />BUSINESS PHONE 125. <br />BUSINESS PHONE 130. <br />(916)622-0137 <br />(888)662-4662 <br />24-HOUR PHONE 126. <br />24-HOUR PHONE 131. <br />(888)662-4662 <br />(888)662-4662 <br />PAGER # N /A 127. <br />PAGER # 132. <br />( N/A <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br />Billing Address: 1755 CREEKSIDE OAKS, SUITE 190 SACRAMENTO,, CA 95833 <br />Property Owner: Phone No.: ( ) <br />Certification. Ba on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and <br />am familiar wit th nformation sub ed and believe the information is true, accurate, and complete. <br />SIGNATURE OF ER/ PE R OR DESIGNATED REPRESENTATIVE <br />DATE 134. <br />NAME OF DOCUMENT PREPARER 135. <br />12/16/2011 <br />KELLY MICHAELS OF EAS <br />NAME OF SIGNER print) 136. <br />TITLE OF SIGNER 137. <br />NICHOLA H. FISCHER <br />MANAGER- ENGINEERING <br />UN -020 V www.unidocs.org 5/17 - Rev. 12/14/10 <br />12 <br />'NN <br />5CRVICL-8 <br />