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UNIDOCS J141V 122 <br />FACILITY INFORMATION <br />1?aoU/NCQ <br />BUSINESS OWNER/OPERATOR IDENTIFICATION PAGPF*F!r,,3a <br />Page of Y <br />L IDENTIFICATION <br />FACILITY ID # <br />1. <br />BEGINNING DATE 100. <br />ENDING DATE 101. <br />(Agency Use Only) <br />H <br />1-1 <br />BUSINESS NAME (Same as Facility Name or DBA -Doing Business As) 3. <br />BUSINESS PHONE 1022. <br />T -MOBILE WEST CORPORATION SITE ID#SC07008A <br />UNMANNED FACILITY <br />BUSINESS SITE ADDRESS 103. <br />BUSINESS FAX 1028. <br />1876 COUNTRY CLUB BLVD. <br />UNMANNED FACILITY <br />BUSINESS SITE CITY 104. <br />ZIP CODE 105. <br />COUNTY los. <br />STOCKTON <br />1 CA <br />95204 <br />SAN JOAQUIN <br />DUN & BRADSTREET 106. <br />06-632-8376 <br />PRIMARY SIC 107• <br />PRIMARY NAICS 107x. <br />4812 <br />517212 <br />BUSINESS MAILING ADDRESS lose. <br />1755 CREEKSIDE OAKS, SUITE 190 <br />BUSINESS MAILING CITY loan• <br />STATE 1081. <br />ZIP CODE 108d <br />SACRAMENTO <br />CA <br />1 <br />95833 <br />BUSINESS OPERATOR NAME 109. <br />BUSINESS OPERATOR PHONE 1 10 <br />T -MOBILE WEST CORPORATION <br />425)383-4000 <br />II. BUSINESS OWNER <br />OWNERNAME T -MOBILE WEST CORPORATION Ill. <br />OWNERPHONE 112. <br />(425) 383-4000 <br />OWNER MAILING ADDRESS 113. <br />12920 SE 38TH STREET <br />OWNER MAILING CITY 114, <br />STATE 115• <br />ZIP CODE 116. <br />BELLEVUE <br />WA <br />98006 <br />III. ENVIRONMENTAL CONTACT <br />CONTACT NAME <br />CONTACT PHONE 118. <br />MICHELLE STEFFLER <br />(916)643-8979 <br />CONTACT MAILING ADDRESS 119. <br />CONTACT EMAIL 119x. <br />1755 CREEKSIDE OAKS, SUITE 190 <br />120. <br />CONTACT MAILING CITY SACRAMENTO <br />STATE 121 • <br />CA <br />ZIP CODE 95833 7 " <br />-PRIMARY- IV. EMERGENCY <br />CONTACTS -SECONDARY- <br />NAMF. 12". <br />NAME <br />NICHOLAS H. FISCHER <br />T -MOBILE WEST NOCC <br />TITLE 124. <br />TITLE <br />MANAGER- ENGINEERING <br />N/A <br />BUSINESS PHONE 125. <br />BUSINESS PHONE 130. <br />(916)622-0137 <br />(888)662-4662 <br />24-HOUR PHONE 126. <br />24-HOUR PHONE 131. <br />(888)662-4662 <br />888 662-4662 <br />127• <br />PAGER # N/A <br />PAGER # 132. <br />( ) N/A <br />ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br />Billing Address: 1755 CREEKSIDE OAKS, SUITE 190 SACRAMENTO,, CA 95833 <br />( ) <br />Property Owner: Phone No.:- \ <br />n <br />Certificatio d on my inquiry of ose individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and <br />am familiar wkttinformation sub t and believe the information is true, accurate, and complete. <br />SIGNATURE WN OPERA OR DESIGNATED REPRESENTATIVE <br />DATE 134. <br />NAME OF DOCUMENT PREPARER 135. <br />12/16/2011 <br />KELLY MICHAELS OF EAS <br />NAME OF SIG (print) 136. <br />TITLE OF SIGNER 137. <br />NICH S H. FISCHER <br />MANAGER- ENGINEERING <br />UN-020 V www.unidocs.org 5/17 - Rev. 12/14/10 <br />7? <br />V7y <br />%V/Cn3 <br />