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Date run 4/6/2016 3:44:41PM 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 FA0022557 <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 />OW0020119 New Owner ID <br />Owner Name <br />New Cingular Wireless PCS, LLC dba AT&T M <br />Owner DBA <br />OwnerAddress <br />308 S ALARD 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 />FA0022557 10479949 <br />Facility Name <br />AT&T Mobility -1-5 - BENJAMIN HOLT (USID8 <br />Location <br />3143 W BENJAMIN HOLT DR <br />Stockton, CA 95219 <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 />AT&T Mobility <br />Location Code <br />Alt Phone <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Fax <br />EMail : <br />Account ID AR0041249 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / <br />Account Name AT&T Mobility Manager EH&S EPCRA <br />Account Balance as of 4/6/2016: $0.00 <br />Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? -11 <br />ete <br />1926 - HMBP-Unstaffed Network Location PR0539452 EE0000006 - HAZA SAEED Active j 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, 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 andtor <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 TyCheck Number R <br />TA -V"- <br />e by <br />EHD Staff: �(� Date / / Account out: Date / <br />COMMENTS: <br />Ir1VOICe #: <br />&\ M \\ caIs cx\ S)'k 12e1� Yqur 6'bluc v�nii dy <br />