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� g <br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revit 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / /__ INACTIVE <br /> Prior Rorer <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / /_ DELETE <br /> n OWNER FILE <br /> CASE M BILLING PARTY Y / N <br /> OWNER NAME OWNER HOME PHONE ( ) <br /> OWNER DBA RR / OWNER WRK/BUS PH ( ) <br /> ADDRESS <br /> CITY \byCk \L \ 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 N 1 // BILLING PARTY <br /> Y OF EMPLOYEES <br /> FACILITY NAME <br /> FACILITY ADDRESS � TRUST LANDS? Y / N <br /> �,ol � W� W2J \LLf\ :�Jl - —y'0 NOME PH ( ) <br /> LLLL//// �v — <br /> CROSS STREET `^1 ""Il— ' " BUSH )PH <br /> f /i� ( ) <br /> CITY " 'C""' STATE ZIP I !/ <br /> Census BO\S Dist D O I Location Code Q ' City Code <br /> MAILING ADDRESS <br /> CARE OF C�Vt` ('/ SIC CODE <br /> CITY STATE C+ ' ZIP <br /> GENERAL TYPE of BUSINESS at thio FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> // O' <br /> NAILING ADDRESS LP ' �` BUSH PHONE <br /> CARE OF Page IOA <br /> CITY S�� v 6 STATE ZIP ��• <br />