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Date run 10123/2014 8:40:45A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/23/2014 <br /> Record Selection Criteria: Facility ID FA0022635 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN I Fed Tax ID <br /> Owner ID OW0020227 New Owner ID <br /> Owner Name Sprint <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> WorklBusiness Phone 877-347-4457 <br /> Mailing Address P O BOX 7994 <br /> SHAWNEE MISSION, KS 66207 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0022635 10589938 <br /> Facility Name Sprint Cell Site SF03UB073 <br /> Location 9629 N HWY 99 <br /> Stockton, CA 95212 <br /> Phone 877-347-4457 x4 <br /> Mailing Address P.O. Box 7994 <br /> Shawnee Mission, KS 66207 <br /> Care of Sprint <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0041434 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name Sprint Cell Site SF03UB073 (Circle one) <br /> Account Balance as of 10/23/2014: $0.00 <br /> (Circle One) <br /> Transferto Active+lrl <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0539561 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor pro}ect 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 rortify that all operations wlil be performed in accordance with all applicable Ordinance Codes andror Standards and State and,'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: *$25.00 Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Receiv <br /> REHS: Date IV lam/t " Account out: Date d 1 ! <br /> COMMENTS: <br /> ►RATE D Nc1rJ AGS l, C.rc�-S <br />