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Date run 1110/2014 1:07:35PN SAN JO>,✓JIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/10/2014 <br /> Record Selection Criteria: Facility ID FA0022154 <br /> Make changesicorrections In RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0018212 New Owner ID <br /> Owner Name Verizon Wireless <br /> Owner DBA W "' <br /> Owner Address �1 fN',�,� <br /> Home Phone Not Spdcified <br /> Work/Business Phone 866-694-2415 <br /> Mailing Address 255 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022154 10468174 <br /> Facility Name Verizon Wireless: Lathrop Union <br /> Location 815 W Lathrop Rd <br /> Manteca, CA 95336 <br /> Phone 866-694-2415 x <br /> Mailing Address 255 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of Verizon Wireless <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 197-020-11 Ell <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040374 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Verizon Wireless: Lathrop Union (Circle One) <br /> Account Balance as of 1/10/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activelmal <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO538319 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor protect specific,PHSIEHD 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 andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid - Date if <br /> Payment Type Check Number Received b 11 / <br /> RENS: ��. N(r Date�/ llJ / ( Account out: Date /� <br /> COMMENTS: <br /> Naw �A a p(L r�cOJoki <br />