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Date run 5/11/2017 5:04:05PN <br />Run by <br />c <br />SAN JOAQUIN COUNTY ENVIRONME, 'TAL HEALTH DEPARTMENT Report#5021 <br />Record Selection Criteria: Facility ID FA0021471 <br />Facility Information a. <br />OWNER FILE INFORMATION Number of facilities for this owner: 17 <br />Owner ID <br />OW0016711 <br />Owner Name <br />T -MOBILE WEST, LLC <br />Owner DBA <br />METRO PCS SAC <br />Owner Address <br />12920 SE 38th ST <br />BELLEVUE, WA 98006 <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 FA0021471 10187957 <br />Facility Name METRO PCS - SAC214 WHISTLER—THORN <br />Location 9650 N THORNTON RD <br />STOCKTON, CA 95209 <br />Phone 888-313-0188 x <br />Mailing Address 785 ORCHARD DR, STE 200 <br />FOLSOM, CA 95630 <br />Care of METROPCS CA, LLC <br />Location Code 99 - UNINCORPORATED P <br />Bos District 003 - BESTOLARIDES, STEVE <br />APN 07202056 <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 />of 5/11/2017 Pagel <br />Mal - changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SN /Fed Tax ID <br />New Owner ID <br />1 <br />An A / / A % <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0038858 New Account ID: <br />Mail Invoices to Owner Mail Invoices to: Owner / <br />Account Name T -MOBILE WEST, <br />Account Balance as of 5/11/2017:$37 . �rv1y_ <br />Facility / Account <br />(Circle One) <br />D (Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description R rd ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0537366 EE0008709 - JAMIE LIMA Active Y N A —Q) D <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 and/or Standards and State andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 Received by <br />EHD Staff: Date �/�/�� Account out: Date s / s ✓� <br />COMMENTS: <br />Invoice #: <br />