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Date run 8/6/2012 4:25:40PM SAN JO. JIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/6/2012 <br />Record Selection Criteria: Facility ID FA0010738 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0008734 <br />Owner Name <br />VERIZON WIRELESS INC <br />Owner DBA <br />2226 - CalARP PROGRAM PR0514852 <br />Owner Address <br />2785 MITCHELL DR BLD9 1STFL <br />Y <br />WALNUT CREEK, CA 94598 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />925-527-9600 <br />Mailing Address <br />2785 MITCHELL DR BLDG 9 1ST FLR <br />A I D <br />WALNUT CREEK, CA 94598 <br />Care of <br />Active,Exempt <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0010738 <br />Facility Name <br />VERIZON WIRELESS INC <br />Location <br />215 SECOND ST <br />N <br />RIPON, CA 95366 <br />Phone <br />209-599-0070 <br />Mailing Address <br />2785 MITCHELL DR <br />Federal Laws. <br />WALNUT CREEK, CA 94598 <br />Care of <br />DAY, RICHARD <br />Location Code <br />BOS District <br />005 - ORNELLAS, LEROY <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0017738 <br />Mail Invoices to Facility <br />Account Name VERIZON WIRELESS INC <br />Account Balance as of 8/6/2012: $0.00 <br />Program/Element and Description <br />Record ID Employee ID and Name <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 />1441 P 2',b ri /L <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />1926 - HMBP-Unstaffed Network Location PR0513026 <br />EE0002474 - MICHAEL PARISSI <br />Inactive <br />Y <br />N <br />A I D <br />2226 - CalARP PROGRAM PR0514852 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y <br />N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAR(PR0510738 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y <br />N <br />A I D <br />2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATI\oPR0521726 <br />EE0002670 - MUNIAPPA NAIDU <br />Active,Exempt <br />Y <br />N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCH,PR0532731 <br />Inactive <br />Y <br />N <br />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 <br />all operations will be performed in accordance with <br />all applicable Ordinance Codes andror Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />RENS: <br />COMMENTS: <br />' $25.00 = Amount Paid _ <br />Amount Paid <br />Date / / Account out: <br />f �p4 ` -j <br />Date <br />Date <br />Date <br />Received by <br />Date/ / 2 <br />