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Daterun 8/15/2017 11:38:17AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 8/15/2017 Pagel <br /> Record Selection Catena: Facility ID FA0022543 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0020093 New Owner ID <br /> Owner Name METROPCS CA, LLC SAC005 <br /> Owner DBA <br /> OwnerAddress <br /> Home Phone Not Specified <br /> Work/Business Phone 888-313-088 <br /> Mailing Address 785 ORCHARD DRIVE SUITE 200 <br /> FOLSOM, CA 95630 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022543 10452049 <br /> Facility Name METROPC CA, LLC SAC005 <br /> Location 455 Hacienda Dr <br /> Stockton, CA 95209 <br /> Phone 883-130-188 x <br /> Mailing Address 85 ORCHARD DRIVE SUITE 200 <br /> FOLSOM, CA 95630 <br /> Care of METROPCS CA, LLC SAC005 <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 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 AR0041235 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name METROPC CA, LLC SAC005 (Circle One) <br /> Account Balance as of 8/15/2017: $0.00 <br /> (Circle One) <br /> Program/Element and Description Transterto Active/Inactve <br /> Record ID Employee ID and Name Status New Owner? /g�`Ie��e <br /> 1921 -HMBP-Reqular-Primary Location PR0539438 EE0008709-JAMIE LIMA Active Y N A / I / D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSEHD hourly charges associated with this ffacility <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 andor Standards and Sfate and/or <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Tyle Check Number Received b e� <br /> EHD Staff: l .`W 6 Date / / Account out: Date <br /> COMMENTS: <br /> I ► `IS Sl Yl0 VW r�P - ,�� Invoice#: <br /> �3M ma-kria- s <br />