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Date run 812/2017 443:54PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 812/2017 <br /> Record Selection Criteria- Facility ID FA0019345 <br /> Make changesfcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 89 SSN 1 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 295 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of VERIZON WIRELESS INC <br /> FACILITY FILE INFORMATION ��� <br /> Facility IDICERS ID FA0019345 <br /> Facility Name VERIZON WIRELESS - MARIPOSA RD <br /> Location 2584 E MARIPOSA RD <br /> STOCKTON, CA 95202 <br /> Phone 925-527-9600 <br /> Mailing Address 2785 MITCHELL DR BLDG 9 1ST FLOOR <br /> WALNUT CREEK, CA 94598 <br /> Care of VERIZON WIRELESS INC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 17307036 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 AR0034382 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VER ON WIRE JAARIPOSA RD (Circle One) <br /> Account Balance as of 81212017: $ 9 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? o]Dt o <br /> 1921 -HMBP-Reqular-Primary Location PR0537215 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528875 EE0009488-JEFFREY WONG Inactivt Y N AD <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSfEHD 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 and/or Standards and State anddr <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Receive b 1 <br /> EHD Staff: Date 1 1 Account out: Date 1 ! <br /> COMMENTS: <br /> Invoice#: <br />