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Date run 12/24/2014 1:33:51F SAN JOOUIN COUNTY ENVIRONMENTAL HEA& DEPARTMENT Report V5021 <br /> Run by Pagel <br /> Facility Information as of 12/24/2014 <br /> Record Selection Criteria: Facility ID FA0012712 <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: 32 SSNIFed 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 PO Box 63604 <br /> Phoenix, AZ 85082 <br /> Care of SCOTT SANDEFUR <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012712 10184327 <br /> Facility Name COLLEGEVILLE SITE#89308 <br /> Location 16401 SOLA RD <br /> STOCKTON, CA 95215 <br /> Phone 916-364-8190 1, 1—MA 'A (�C, lnnr 1,n 'N' U Li <br /> Mailing Address <br /> Care of <br /> Location Code 99- UNINCORPORATED,6 Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 18310012 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 AR0021188 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name COLLEGEVILLE SITE#89308 (Circle One) <br /> Account Balance as of 1212412014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Q <br /> Dellete <br /> 1926-HMBP-Unstaffed Network Location PRO521192 EE00OB709-JAMIE DE LA ROSA Active Y N A D <br /> 2220-SM HWGEN<5 TONS/YR PRO516619 EE0001421 -STACY RIVERA InactivE Y N A D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0516620 EE0000008-LETITIA BRIGGS InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 andfor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Check Number Receive y <br /> RENS: Date 1� 1 1 Account out: Date ! 1 7 <br /> COMMENTS: <br />