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Date run d 4/8*315 11:19:28AM SAN JC UIN COUNTY ENVIRONMENTAL HEA i DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 4/8/2015 <br />Record Selection Criteria: Facility ID FA0020353 <br />p ake changesicorrections in RED ink. <br />COPY INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 17 SSN /Fed Tax ID <br />Owner ID OW0016711 New Owner ID : <br />Owner Name T -MOBILE WEST CORPORATION <br />Owner DBA <br />METRO PCS SAC <br />Owner Address <br />12920 SE 38th ST <br />Location <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 />T -MOBILE WEST CORPORATION <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0020353 10609621 <br />Facility Name <br />METRO -PCS SAC010 <br />Location <br />50 Turner Rd <br />Lodi, CA 95242 <br />Phone <br />888-662-4662 x <br />Mailing Address <br />1755 Creekside Oaks Dr., Suite 190 <br />Sacramento, CA 95833 <br />Care of <br />T -MOBILE WEST CORPORATION <br />Location Code <br />99 - UNINCORPORATED A <br />Bos District <br />004 - WINN, CHARLES <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0036340 <br />Mail Invoices to Account <br />Account Name METRO- C010 <br />Account Balance as of 4/8/20 $ 0 <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />_ Transfer to Active/Inactve <br />o r ent and Description Record ID Employee ID a Status New Owner? /DQeete <br />-t927--hIM3P-Regular-Primary Location PR0535238 EEO 8709 - JAMIE DE LA ROSA —Aebve-- Y N A (I / D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO535300 Inactiv( Y N A `-f 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 and/or <br />Federal Laws C <br />APPLICANT'S SIGNATURE. / Date �f / 8 /—LS7- <br />Program Records to be TRANSFERED: " $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment yp Check Number Received lav <br />REHS: L Date /71/ Account out: Date 7 /1g <br />COMMENTS: <br />