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Date run 1/24/2014 11:33:50AI SAN JO� D UIN COUNTY ENVIRONMENTAL HEADEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/24/2014 <br /> Record Selection Criteria: Facility ID FA0022130 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 2 �' <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0009900 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 FA0022130 10405669 <br /> Facility Name AMERICAN TOWERS GALT CA SITE#8256: <br /> Location 28499 NICHOLS RD <br /> GALT, CA 95632 <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 00508040 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 AR0040350 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AMERICAN TOWERS GALT CA SITE#82565 (Circle 0.) <br /> Account Balance as of 1/24/2014: $0.00 <br /> (Circle One) <br /> Transfer to ActivvirmaNe <br /> Progran✓Element and Description Record ID Employee ID and Name Status New 0.0 Delete <br /> 1926-HMBP-Unstaffed Network Location PRO538286 EE0008709-JAMIE DE LA ROSA Active,I Y N Ali D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project 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 certify that all operations will be performed in accordance with all applicable Ordinance Codes anal Standards and Stale ander <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 T a Check Number Recelv y <br /> RENS: P1• V^a �ii Date / /_1_�:J Account out: <br /> COMMENTS: <br /> Pl Qat �fill, A-41 V� P i �2� <br />