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Date run 8/11/2017 2:06:0013Iv SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 8/11/2017 Pagel <br /> Record Selection Criteria: Facility ID FA0021374 <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: 17 SSN/Fed Tax ID <br /> Owner ID OW0016711 New Owner ID <br /> Owner Name T-MOBILE WEST CORPORATION <br /> Owner DBA METRO PCS SAC <br /> Owner Address 12920 SE 38th ST <br /> BELLEVUE, WA 98006 <br /> Home Phone 888-313-0188 <br /> Work/Business Phone 425-383-4000 <br /> Mailing Address 12920 SE 38th Street <br /> Bellevue, WA 98006 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021374 10187829 <br /> Facility Name METRO PCS SAC-491A <br /> Location 14766 E HWY 12 <br /> LOCKEFORD, CA 95209 <br /> Phone 888-313-0188 x <br /> Mailing Address 785 ORCHARD DR SUITE 200 <br /> FOLSOM, CA 95630 <br /> Care of METROPCS CA, LLC <br /> Location Code 99-UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 01912005 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 888-313-0188 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0038739 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name METRO PCS SAC-491A (Circle One) <br /> Account Balance as of 8/11/2017: $0.00 <br /> (Circle One) <br /> Proram/Element and Description Transfer to Aclivednai <br /> 8 P Record ID Employee ID and Name Status New Ownnn Delete <br /> 1921 -HMBP-Regular-Primary Location PR0537247 EE0008709-JAMIE LIMA Active Y N A / I 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSEHD hourly charges associated with this/ <br /> facility 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 an Stendartls <br /> and State ani Federal Laws <br /> APPLICANT'S SIGNATURE: Date / ! <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Tye Check Number Receivedy <br /> EHD Staff: ��Cpl,_. Date Account out: Date <br /> COMMENTS: <br /> Invoice#: <br /> �� INV IM cffaw <br />