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SAN JOAQUIN -�ozn1NTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL h__,TH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 8/26/93 <br /> NEW-,JCS,, Y��Q�Jgrom CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> adder , e-x�+'raC. Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> OWNER ID 2 CASE # BILLING PARTY Y / N <br /> OWNER NAME pp OWNER HOME PHONE ( ) <br /> OWNER DBA C_ S D rI/�/ OWNER WRK/BUS PH (-2 - <br /> OWNER ADDRESS �• O <br /> OWNER CITY ,�1 D1 \ STATE ZIP ✓ZO <br /> MAILING ADDRESS � /� ') <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS 50 IK 46 kl <br /> FACILITY FILE <br /> FACILITY ID # oZ9 BILLING PARTY Y / N <br /> 1;2-to <br /> OF EMPLOYEES <br /> FACILITY NAME �D rD Q TRUST LANDS? Y / N <br /> FACILITY ADDRESS O QV D r1`"��L HOME PH ( ) <br /> CROSS STREET L m I BUSN PH ( ) <br /> CITY �- VC, a STATE ZIP ! ✓ Z06 <br /> Census --------- BOS Dist Location Code City Code ------ - - <br /> MAILING ADDRESS APN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP rr- <br /> GENERAL TYPE of BUSINESS at this FACILITY b u lK Fa <br /> UST FAC STATUS CODE 60 <br /> BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS BUSH PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />