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Date run 1/24/2014 11:37:11AI SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by t{ Pagel <br /> Facility Information as of 1/24/2014 <br /> Record Selection Criteria: Facility ID FA0022137 <br /> Make changes/corrections in RED ink. Z� <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 FA0022137 10406683 <br /> Facility Name AMERICAN TOWERS PORT OF STOCKTON <br /> Location 734 WILSHIRE AVE <br /> STOCKTON, CA 95203 <br /> Phone 602-284-0280 <br /> Mailing Address PO BOX 63604 <br /> PHOENIX, AZ 85082 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOB District 001 -VILLAPUDUA Fax <br /> APN 13320016 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 AR0040357 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AMERICAN TOWERS PORT OF STOCKTON#8261 (Circle One) <br /> Account Balance as of 1/24/2014: $0.00 <br /> (Circle One) <br /> Transfer to Aclivellnaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner' elate <br /> 1926-HMBP-Unstaffed Network Location PR0538293 EE0009817-ROBERT LOPEZ Active,l Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor 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 andor Standards and State andor <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 T a Check Number Recei <br /> REHS: U�k&J Date / / Account out: <br /> COMMENTS: <br /> P( a.ory� a n 4tr F 1 1 Z( . <br /> Ar �k �Urd lei' <br />