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Date run 12/23/2016 9:01:41A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by <br /> Facility Information as of 12/23/2016 Pagel <br /> Record Selection Critena: Facility ID FA0022136 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 32 SSN/Fed Tax ID <br /> Owner ID OW0009900 New Owner ID <br /> Owner Name AMERICAN TOWERS- EH&S Dept. <br /> Owner DBA AMERICAN TOWER <br /> Owner Address 10 PRESIDENTIAL WAY <br /> WOBURN, MA 01801 <br /> Home Phone 602-284-0280 <br /> Work/Business Phone 602-999-5139 <br /> Mailing Address 10 Presidential Way <br /> Woburn, MA 01801 <br /> Care of SCOTT SANDEFUR <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022136 10406224 <br /> Facility Name AMERICAN TOWERS MANTECA NORTH#1( <br /> Location 10988 E SOUTHLAND RD <br /> MANTECA, CA 95336 <br /> Phone 602-284-0280 <br /> Mailing Address PO BOX 63604 <br /> PHOENIX,AZ 85082 <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 003-BESTOLARIDES, STEVE Fax <br /> APN 20807010 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 AR0040356 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AMERICAN TOWERS MANTECA NORTH #1008 (CIroe One) <br /> Account Balance as of 12/23/2016: $0.00 <br /> (Circle One) <br /> Transfer to Active9nacive <br /> Program/Element and Descdpgon Record ID Employee ID antl Name Status Nww nwnw ,late <br /> 1926-HMBP-Remote Network Location PRO538292 EE0000009-NICHOLAS LOEHRER Active,l Y N A U D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent or same,acknowledge that all site,andior project specPa,PHSIEHO hourly charges associated with this <br /> facility or aotivay,will 0a billetl to the party identified as the OWNER on this form. I also rartify that all operations will be performetl in accordance with all applicable Ordinance Codes andor Standards <br /> and State an6or 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 Type Check Number Received by <br /> EHD Staff: Date �,7— / 23 Account out: Date / / 6 <br /> COMMENTS: <br /> Invoice#: p <br /> �`�l, G�Yy�c�5 � �V�;.S �o cv�\!.c� `�)wrY, � V CK .`�•(\ \�Q,�sL <br />