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Date run 5//2017 5:05:54PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by r Pagel <br />Facility Information as of 5/11/2017 <br />Record Selection Criteria: Facility ID FA0021464 <br />OWNER FILE INFORMATION Number of facilities for this owner: 17 <br />owner ID OW0016711 <br />Owner Name T -MOBILE WEST, LLC <br />Owner DBA METRO PCS SAC <br />Owner Address 12920 SE 38th ST <br />BELLEVUE, WA 98006 <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 />Home Phone <br />888-313-0188 <br />Work/Business Phone <br />425-383-4000 <br />Mailing Address <br />12920 SE 38th Street <br />Bellevue, WA 98006 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0021464 10187943 <br />Facility Name <br />METRO PCS INC SITE SAC 128 STOCKTON <br />Location <br />116 FYFFE AVE <br />Stockton, CA 95203 <br />Phone <br />888-313-0188 x <br />Mailing Address <br />785 ORCHARD DR, STE 200 <br />FOLSOM, CA 95630 <br />Care of METROPCS CA, LLC <br />Location Code 01 - STOCKTON <br />Bos District 002 - MILLER, KATHERINE <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name JENNIFER BANGLOS <br />Title <br />Day Phone 916-984-2652 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0038851 <br />Mail Invoices to Owner <br />Account Name T -MOBILE WES , LLC <br />Account Balance as of 5/11/2017: $ t_,-.. <br />EMail : <br />O's n <br />..v, ZJI 7 int S <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0537359 EE0009817 - ROBERT LOPEZ Active Y N AD <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 all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: ` $25.00 = <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: Date <br />COMMENTS: <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Received y <br />Account out: Date /-j r <br />Invoice #: <br />�,7,)/q <br />