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SAN JOADUIOTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER GATE OF OWNER CHANGE / /_ INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANCE OF BILLING DATE OF BILLING CHANGE / /_ DELETE <br /> OWNER FILE <br /> OWNER 10 005�a�7 CASE # BILLING PARTY Y / N <br /> OWNER NAME OWNER HOME PHONE ( ) <br /> OWNER DBA OWNER WRK/BUS PH ( ) <br /> ADDRESS <br /> CITY STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # '7 0 9'�- BILLING PARTY <br /> # OF EMPLOYEES <br /> TRUST LANDS? Y / N <br /> FACILITY NAME�1��`Pi� - 1 � � <br /> i <br /> FACILITY ADDRESS 1)�� c jY '� 1�� HOME PH ( 7 <br /> ( ) <br /> CROSS STREET BUSH PH <br /> CITY �� %I--'b�+'1 STATEZIP -� � '-G�. 0 <br /> Census BOS Dist Location Cade City Code ----------- <br /> APN # <br /> MAILING ADDRESS <br /> SIC CODE <br /> CARE OF <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( 7 <br /> MAILING ADDRESS 8USN PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />