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Date run 4/6/2016 3:50:47PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 4/6/2016 <br />Record Selection Criteria: Facility ID FA0022555 <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 : 1 SSN / Fed Tax ID <br />Owner ID <br />OW0020115 New Owner ID <br />Owner Name <br />New Cingular Wireless PCS, LLC dba AT&T M <br />Owner DBA <br />Owner Address <br />308 SAKARD ST 1708 <br />DALLAS, TX 75202 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />214-464-2626 <br />Mailing Address <br />308 S AKARD ST RM 1708 <br />DALLAS, TX 75202 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022555 10479943 <br />Facility Name <br />AT&T Mobility - HWY 120 - S MAIN ST (USIDf <br />Location <br />1153 Vanderbilt Cir <br />Manteca, CA 95337 <br />Phone <br />800-638-2822 x <br />Mailing Address <br />308 S AKARD ST RM 1708 <br />DALLAS, TX 75202 <br />Care of <br />Location Code <br />Alt Phone <br />BOS District <br />Fax <br />APN <br />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 <br />AR0041247 New Account ID: <br />Mail Invoices to <br />Account Mail Invoices to: Owner / Facility / Account <br />Account Name <br />AT&T Mobility Manager EH&S EPCRA (Circle One) <br />Account Balance as of 4/6/2016: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? 6elete <br />1926 - HMBP-Unstaffed Network Location PR0539450 EE0000010 - PETER LOMBARDI Active,I Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD 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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 Re <br />EHD Staff: �.` Date / / Account out: Date / (O A � <br />COMMENTS: <br />Ir1V01Ce #: <br />C4rv�ckA un �� acre. Vaew r-ew 4bu- "Xn�, <br />