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Date run 11/3/2015 8:22:41AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 11/3/2015 <br />Record Selection Criteria: Facility ID FA0023200 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0021333 <br />Owner Name Verizon Wireless <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 866-694-2415 <br />Mailing Address 295 Parkshore Drive <br />Folsom, CA 95630 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0023200 10641604 <br />Facility Name <br />Verizon Wireless Buckley <br />Location <br />5415 Feather River Dr <br />Stockton, CA 95219 <br />Phone <br />866-694-2415 x <br />Mailing Address <br />295 Parkshore Drive <br />Folsom, CA 95630 <br />Care of <br />Verizon Wireless <br />Location Code <br />BOS District <br />APN <br />116-110-03 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/ Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail <br />Account ID AR0042629 <br />Mail Invoices to Account Mail Invoices to: <br />Account Name Environmental Compliance <br />Account Balance as of 11/3/2015: $0.00 <br />New Account ID: : <br />Owner / 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? Delete <br />1926 - HMBP-Unstaffed Network Location PR0540558 EE0000006 - HAZA SAEED Active Y N A I 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 />Program Records to be TRANSFERED: * $25.00 = <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: Date ! / <br />COMMENTS: <br />Date 1 /. <br />Amount Paid Date <br />_ Amount Paid Date <br />Received by <br />Account out: Date I L <br />1f 2.CVIvC/W F At.► 1,1 rl J- P A -O Cr 21kY�-, <br />V cle-a'S . <br />Invoice #: <br />