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Date run 6/13/2014 11:17:27AI SAN JIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Repod#5021 <br /> Run by Pagel <br /> Facility Information as of 6/13/2014 <br /> Record Selection Criteria: Facility ID FA0019327 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 97 SSN/Fed Tax ID <br /> Owner ID OW0008734 New Owner ID <br /> Owner Name Verizon Wireless <br /> Owner DBA <br /> Owner Address 255 PARKSHORE DR <br /> FOLSOM, CA 95630 <br /> Home Phone 866-694-2415 <br /> Work/Business Phone 866-694-2415 <br /> Mailing Address 255 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of VERIZON WIRELESS INC <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019327 10144371 <br /> Facility Name VERIZON WIRELESS-MOSSDALE SITE <br /> Location 1375 E MADRUGA RD —r)L D IA A r--L) <br /> LATHROP, CA 95330 <br /> Phone 925-527-9600 <br /> Mailing Address 2785 MITCHELL DR BLDG 9 1ST FL <br /> WALNUT CREEK, CA 94598 <br /> Care of VERIZON WIRELESSINC <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 24141038 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034347 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VERIZON WIRELESS - MOSSDALE SITE (Circle One) <br /> Account Balance as of 6/13/2014: $0.00 <br /> (Circle One) <br /> Transfer to ALdveQnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0512994 EE0006044-LOWELL ALLEN Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510706 EEo000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528a47 EE0002670-MUNIAPPA NAIDU Active,l Y N A I 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 thisfacility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that all operations will be perlormed in accordance with all applicable Ordinance Codes and/or Standards and State anNor <br /> Federal Laws. <br /> APPLICANT'S 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 Re y <br /> REHS: X1 Wn Date_S�/1 j_/ Account out: Date <br /> COMMENTS: <br /> -rr�c� address per �� r c.-�l U1�e�•�er-: <br />