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Date run„ 11/1:/2013 9:04:40A SAN JO*IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#sort <br /> Run by Pagel <br /> Facility Information as of 11/19/2013 <br /> Record Selection Criteria: Facility ID FA0010706 <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 Q;4e 73a'eqk— New Owner ID <br /> Owner Name VERIZON WIRELESS INC <br /> Owner DBA <br /> Owner Address 2785 MITCHELL DR BLD9 1STFL <br /> WALNUT CREEK, CA 94598 <br /> Home Phone 925-527-9600 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2785 MITCHELL DR BLDG 9 1ST FLR <br /> WALNUT CREEK, Ck 94598 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID 10,144,371 <br /> Facility Name VERIZON -MOSSDALE CELL SITE <br /> Location 1250 E MADRUGA RD <br /> LATHROP, CA 95330 <br /> Phone 925-527-9600 <br /> Mailing Address 2785 MITCHELL DR <br /> WALNUT CREEK, CA 94598 <br /> care of RICHARD DAY <br /> Location Code Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 24141038 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMA�O11/�N <br /> Account ID A-ill 70$ New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name VERIZON -MOSSDALE CELL SITE (Circle One) <br /> Account Balance as of 11/19/2013: $0.00 <br /> (Circle One) <br /> Transferto Acgve/Inadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PRO512994 EE0006044-LOWELL ALLEN Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510706 EEOO00000-HAZ MAT SJC IDES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersignetl owner,operator or agent of same,acknowledge that all site,andor project specific,PHStEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certity that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andar <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 Receiiyod'{y I <br /> REHS: Date / /_ Account out: ` 1�__ Date 7L/ LL->, <br /> COMMENTS: ',r�1jyA,V,7L V�,�..'. Kff -/y 1 <br /> ���JJJVVVJJJVVV // /N/IHA!' �� lYI©7 !! J�jorj(�R <br />