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Date run 1/24/2014 11:44:42AI SAN JO, 11N COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by \rw Paget <br /> Facility Information as of 1/24/2014 <br /> Record Selection CriteriaFacility ID FA0022109 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0009900 New Owner ID <br /> Owner Name AMERICAN TOWERS <br /> Owner DBA AMERICAN TOWER <br /> Owner Address PO BOX 63604 <br /> PHOENIX, AZ 850823604 <br /> Home Phone 602-284-0280 <br /> Work/Business Phone 602-284-0280 <br /> Mailing Address P.O. BOX 63604 <br /> PHOENIX, AZ 85082 <br /> Care of SCOTT SANDEFUR <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022109 10405810 <br /> Facility Name AMERICAN TOWERS HOWARD RD#41147 <br /> Location 7878 UNDINE RD <br /> STOCKTON, CA 95206 <br /> Phone 602-284-0280 <br /> Mailing Address PO BOX 63604 <br /> PHOENIX, AZ 85082 <br /> Care of AMERICAN TOWER <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 18921020 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040325 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AMERICAN TOWERS HOWARD RD#41147 (Circle One) <br /> Account Balance as of 1/24/2014: $0.00 <br /> (Circle One) <br /> Transferto ActivePnareve <br /> ProgradVElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0538257 EE0008709-JAMIE DE LA ROSA Active Y N A O D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,ander 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 ander Standards and State andlor <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 Type heck Number Recei <br /> REFS: 7 Date _/ /�� Account out: Date / <br /> COMMENTS'. <br />