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Date run 8/20/2014 8:59:14AN SAN JOAN COUNTY ENVIRONMENTAL HEAI��EPARTMENT Repar*5021 <br /> Run by Pagel <br /> Facility Information as of 8/20/2014 <br /> Record Selection Criteria: Facility ID FA0022543 <br /> Make changes/corrections 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 to <br /> Owner ID OW0020093 New Owner ID <br /> Owner Name METROPCS CA, LLC SAC005 <br /> Owner DBA <br /> Owner Address <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 /> BOS 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 New Account 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 8/20/2014: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0539438 EE0008709-JAMIE DE LA ROSA Active/Ex 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,PHSrEHD 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 andor Standards and State ardor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Rete' <br /> REHS: �— Date_/ / t� Account out: Date / /Jf4 <br /> COMMENTS: <br /> C R-eW rr� A-(.L Lt-wj r P�✓� 2 nwt V%pr <br /> re-*C-V%'%f T <br />