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Date nun 8/6/2012 4:23:38PM SAN JO.,.IIN COUNTY ENVIRONMENTAL HEAI DEPARTMENT Report 051)21 <br /> .. <br /> Run by sr Pagel <br /> Facility Information as of 8/6/2012 <br /> Record Selection Cri eda: Facility ID FA0010735 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008734 New Owner ID <br /> Owner Name VERIZON WIRELESS INC <br /> Owner DBA <br /> Owner Address 2785 MITCHELL DR BLD9 1STFL <br /> WALNUT CREEK, CA 94598 <br /> Home Phone Not Specified <br /> Work/Business Phone 925-527-9600 <br /> Mailing Address 2785 MITCHELL DR BLDG 9 1ST FLR <br /> WALNUT CREEK, CA 94598 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010735 <br /> Facility Name VERIZON WIRELESS- LINDEN <br /> Location 19054 E HWY 26 I 05 4AA1 St� <br /> LINDEN, CA 95236 <br /> Phone 209-239-0258 <br /> Mailing Address 2785 MITCHELL DR <br /> WALNUT CREEK, CA 94598 <br /> Care of DAY, RICHARD <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOIS District 004 -VOGEL, KEN Fax <br /> APN 10517046 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account lD AR0017735 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name VERIZONWIRELESS- LINDEN (CucleOne) <br /> Account Balance as of 8/6/2012: $0.00 <br /> (Circe One) <br /> Transfer to Activemactve <br /> PropraMElement and Descriptlon Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO513023 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2226-CaiARP PROGRAM PR0514849 EEo000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510735 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0528892 EE0009488-JEFFREY WONG Active,Exempt Y N A I D <br /> BILLING and COMPLMCE ACKNOWLEDGEMENT: I,Ne undlemigned owner,operator or agent of Same,acknowledr)8 Nat all site,andlor project specti(c,PHSIEHO hourly omegas associated with Nis facility <br /> or activity will be billed to the,party identified as tie OWNER on Nis form I also oedM that all oP Metions will be performed in accordance wird all applicable Ordinance Codes andor Standards and State andor <br /> 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 /> REHS: Date / / Account out: �'JJ Date <br /> COMMENTS: <br /> pA ®�s <br />