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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH pZVZSZON <br /> MASTERFILE RECORD INFORMATION FORM EH OZ IS <br /> (OwNFAC), Revis 8/26/93 <br /> NEW FACILITY CHANGE OF OWNER <br /> DATE OF OWNER CHANGE <br /> Prior Owner / / nIVB <br /> UNDER CONSTRQCTION CHANGE OF BILLIN, <br /> DATE OF B / / <br /> DELETE <br /> OWNER FILE <br /> OWNER ID <br /> (01SE # BILLING PARTY <br /> M Y / g <br /> OWNER NAME' ,' ` x L <br /> OWNER ROM PHONE ( ) <br /> OWNER DBA <br /> OWNER WRK/BUS PH ( )' <br /> OWNER ADDRESS pZC1^ <br /> OWNER CITY ~ STATE%— 1— ZIP <br /> ING ADDRESS <br /> d CARE OF <br />'1 <br /> CITY STATE <br /> ZIP <br /> i <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # �� BILLING PARTY Y / N <br /> WL E d # OF EMPLOYEES <br /> ,Ty <br /> NAME O IT�E'�J p Vit IG�.i►e� y�G TRUST LANDS? Y / N <br /> AGILITY ADDRESS —1 o--�ZN. e-`k{T IA,, t HOME PH ( ) <br /> CROSS STREET <br /> CITY ,Y W-Q J BUM PH (2 pq l 33�_- 02 II oL <br /> L Gd: STATE � ZIP C'l <br /> Census --------- BOS Dist Location Code City Code <br /> ---------7m-1 <br /> ,[AILING ADDRESS S d t,J nJ N�, ` `'Z ARM # - ©t l'"l�Q ^ <br /> �+ q <br /> CARE OF _ p b C 1 T G k1 le f sic CODE L l_XJ <br /> CITY t.o C STATE C "` ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> QST FAC STATUS CODE BusmESs CODE BUSINEss TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HONE PHONE ( ) <br /> ,ILING ADDRESS <br /> BUSN PHONE ( ) <br /> CARE OF <br /> s <br /> CITY <br /> STATE ZIP <br />