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Data run 11124/2008 4:24:16P SAN JC1(JQ1/COUNTY ENVIRONMENTAL HEA' H DEPARTMENT <br /> Report#5021 <br /> ` <br /> Run by #' Pagel <br /> Facility Information as of 11/24/2 <br /> Record Selection Criteria'. Facility ID FA0010735 <br /> Make changeslcorrections in RED ink or pencil. <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 1 STFL <br /> WALNUT CREEK, CA 94598 <br /> Home Phone Not Specked <br /> WorkBusiness 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 4A41N-ST f H 210 <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 /> BOS 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 ID AR0017735 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name VERIZONWIRELESS -LINDEN Circle One) <br /> Account Balance as of 11/24/2008: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> PrograMElement and Description Record ID Employee to and Name Status New Owner's Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513023 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2226-CalARP PROGRAM PRO514849 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO510735 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0528892 EE0000753-WILLY NG Active,Exempt Y N A I D <br /> BILLING am COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned ower,operator or agent of same.acknowiedge that all site.ardlor project spemfic.PHSIEHD hourly charges associated with this <br /> facility or activity,will be billed to the Parry identified as the OWNER on this form. I also certify that all operations will be Performed in accordance with all applicable Ordinate Codes andlor Standards am <br /> State and/or Federal taws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date f__/_ <br /> Payment Type Check Number Receiv <br /> RENS: LN•IJ(r Date 11 / 2N / O eA Atxount out: Date / <br /> COMMENTS: <br /> V";L'o )(, Sz'a-E.� N etc <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />