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Date 1 1 1/24/2014 1:05:31 PI, SAN JO` 'UIN COUNTY ENVIRONMENTAL HEAT,.;DEPARTMENT Report 95021 <br /> Run 6y �/ Pagel <br /> Facility Information as of 1/24/2014 <br /> Record Selection Criteria. Facility ID FA0022142 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date 2�1 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OWOOO9900 New Owner ID <br /> Owner Name AMERICAN TOWERS <br /> Owner DBA AMERICAN TOWER <br /> Owner Address PO BOX 63604 <br /> PHOENIX, AZ 850823604 <br /> Home Phone 602-284-0280 <br /> Work/Business Phone 602-284-0280 <br /> Mailing Address P.O. BOX 63604 <br /> PHOENIX,AZ 85082 <br /> Care of SCOTT SANDEFUR <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022142 10406443 <br /> Facility Name AMERICAN TOWERS FIVE CORNERS#411, <br /> Location 13415 S LONE TREE RD <br /> MANTECA, CA 95336 <br /> Phone 602-284-0280 <br /> Mailing Address PO BOX 63604 <br /> PHOENIX, AZ 85082 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 20305010 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040362 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AMERICAN TOWERS FIVE CORNERS#41146 (Circle One) <br /> Account Balance as of 1/24/2014: $0.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0538298 EE0002474-MICHAEL PARISSI Active,l Y N A 6) D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor 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 andor Standards and State ands <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 <br /> Payment type Check Number Rece' <br /> REHS: Date / / Account out: Date 1.17-171 <br /> COMMENTS: <br />