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Date run 12/22/2016 3:40:31P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report x5021 <br /> Run by <br /> Facility Information as of 12/22/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0022135 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) \Z I Z?I 1 L. <br /> OWNER FILE INFORMATION Number of facilities for this owner: 32 SSN/Fed Tax ID <br /> Owner ID OW0009900 New Owner ID <br /> Owner Name AMERICAN TOWERS - EH&S Dept. <br /> Owner DBA AMERICAN TOWER <br /> Owner Address 10 PRESIDENTIAL WAY <br /> WOBURN, MA 01801 <br /> Home Phone 602-284-0280 <br /> Work/Business Phone 602-999-5139 <br /> Mailing Address 10 Presidential Way <br /> Woburn, MA 01801 <br /> Care of SCOTT SANDEFUR <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022135 10406149 <br /> Facility Name American Tower- Manteca, Site#82588 <br /> Location 20741 Jack Tone Rd <br /> Ripon, CA 95366 <br /> Phone 602-284-0280 x <br /> Mailing Address PO Box 63604 <br /> Phoenix,AZ 85082 <br /> Care of American Tower <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> Bos District 004 -WINN, CHARLES 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 AR0040355 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name American Tower- Manteca, Site#82588 (Gmle one) <br /> Account Balance as of 12/22/2016: $0.00 <br /> (Circle One) <br /> Transfer to Adivadlnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New nwnan ;D\elete <br /> 1926-HMBP-Remote Network Location PRO538291 EE0000009-NICHOLAS LOEHRER Active,l Y N ( <br /> A (' i D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project speck,PHSrEHD hourly charges asaociated with this <br /> facility 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 ander Standards <br /> and State andor 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 Type Check Number Reoelved y <br /> EHD Staff: Date Account out: Date A/ -A / 74 <br /> COMMENTS: <br /> Invoice#* <br /> ••�S:^�O.,SS �� '.LC��I yA \ O I Nef <br />