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Date run 6/13/2014 9:43:07Ah SAN JO"I"l-/JIN COUNTY ENVIRONMENTAL HEA"%-ObEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/13/2014 <br /> Record Selection Criteria: Facility ID FA0019359 <br /> Make changesicorrections in REI]ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 97 SSN/Fed Tax ID <br /> Owner ID OW0008734 New Owner ID <br /> Owner Name Verizon Wireless <br /> Owner DBA <br /> Owner Address 255 PARKSHORE DR <br /> FOLSOM, CA 95630 <br /> Home Phone 866-694-2415 <br /> Work/Business Phone 866-694-2415 <br /> Mailing Address 255 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of VERIZON WIRELESS INC <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0019359 10143903 <br /> Facility Name VERIZON WIRELESS -JACKTONE <br /> Location 13613 E HWY26 ' t&kj N. a1AC_*- 'ronX RVJ <br /> LINDEN, CA 95236 <br /> Phone 925-527-9600 <br /> Mailing Address 2785 MITCHELL DR BLDG 9 1ST FLOOR <br /> WALNUT CREEK, CA 94598 <br /> Care of VERIZON WIRELESS INC <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 09105032 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name VERIZON WIRELESS INC <br /> Title <br /> Day Phone 925-527-9600 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034398 New Account ID: : <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name VERIZON WIRELESS-JACKTONE (Circle One) <br /> Account Balance as of 6/13/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Bement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0537234 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528893 EE0002670-MUNIAPPA NAIDU Active,l Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSlFHD hourly charges associated with this facility <br /> or activity w1l be billed to the party identified as the OWNER on this form I also certify that all operations WN be performed in accordance with all applicable Ordinance Codes andfor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date ! 1 <br /> Payment Type Check Number Recei e <br /> .f <br /> REHS: 1�' .VFa Date. (,i 1 I t I Account out: Date 1 l <br /> COMMENTS: <br /> e <br />