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Date run 30/2013 4:50:30PM SAN JOill.,TIN COUNTY ENVIRONMENTAL HEAL,_,O,DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 3I7I2013 <br /> Record Selection Crilena: Facility ID FA0010883 <br /> Make changesfoorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008883 Case Number: H08920 New Owner ID <br /> Owner Name USA MOBILITY <br /> Owner DBA USA MOBILITY <br /> Owner Address 4211 CORONADO AVE STE A <br /> STOCKTON, CA 95204 <br /> Home Phone Not Specified <br /> Work/Business Phone 800-611-8488 <br /> Mailing Address 4211 E CORONADO AVE 22000 t6h" 0� <br /> STOCKTON, CA 95204 -7(1(- <br /> Care <br /> rfCare of Akrl- U yfl)-J <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010883 <br /> Facility Name USA MOBILITY <br /> Location 4211 CORONADO AVE STE A <br /> STOCKTON, CA 95204 <br /> Phone 800-468-3908 x0 <br /> Mailing Address 4211 E CORONADO AVE 0 lA �U D <br /> STOCKTON, CA 95204 TX 7 0 f <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 11530034 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 AR0017883 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name USA MOBILITY (Circle One) <br /> Account Balance as of 3/7/2013: $305.00 <br /> (Circle One) <br /> Transfer to Activednacive <br /> ProgranYElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520533 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO513171 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510883 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO534273 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acl ncrWedge that all site,anUor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as me OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andia <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 Received by <br /> REHS: Date / / Account out: Date )3' <br /> COMMENTS: III <br /> �v� 312 N <br />