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Date run 9/14/201210:35:23AI SANJO `AN COUNTY ENVIRONMENTAL HEADDEPARTMENT <br /> Run by *400r Report 115021 <br /> Facility Information as of 9/14/20 page' <br /> Record Selection Criteria: Facility ID FA0019329 <br /> Make changesicorrections 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 925-527-9600 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2785 MITCHELL DR BLDG 9 IST FLR <br /> WALNUT CREEK, CA 94598 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019329 <br /> Facility Name VERIZON WIRELESS -SOUTH BIRD <br /> Location 37651 S BIRD RD <br /> TRACY, CA 95376 <br /> Phone 925-527-9600 <br /> Mailing Address 2785 MITCHELL DR BLDG 9 1ST FL <br /> WALNUT CREEK, CA 94598 <br /> Care of VERIZON WIRELESS INC <br /> Location Code Aft Phone <br /> BOS District Fax <br /> APN 26507013 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 AR0034349 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VERIZONWIRELESS -SOUTH BIRD (Circle One) <br /> Account Balance as of 9/14/2012: $0.00 <br /> (Circle One) <br /> Transferto ActiveJlnactve <br /> PrograndElement and Description Record ID Employee ID and Name Status New Owner? 4AIlets <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528849 EE0002646-THUY TRAN Active,Exempt Y N AI D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,ardor project spedfc,PHS/EHD hourly charges associated with aclily <br /> or activity will be billed to the party identified as the OWNER on Nis form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and Stale ander <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 / I <br /> Payment Type Check Number Recei 11 � <br /> REHS: �. Date�/ /� Account out: Data / /L <br /> COMMENTS: <br />