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tip L-2- <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISIONEN 01 15 (OWHfAC) Revis 5/14/93 <br /> MASTERFILE RECORD INFORMATION FORM <br /> 7UNDER <br /> ITY CHANGE OF OWNER <br /> DATE OF OWNER CHANGE INACTIVE <br /> Prior Owner DELETE <br /> STRUCTIONCHANGE Of BILLING <br /> DATE OF BILLING CHANGE /�J <br /> OWNER FILE <br /> �+ CASE # BILLING PARTY Y / N <br /> OWNER NAME Be�i'��Ir� t�r-,,"C, yr,- OWNER H014E PHONE C ) <br /> OWNER WRK/BUS PH C ) <br /> OWNER DBA C, <br /> ADDRESS ll ✓ r ta- Cc)L)` 7f <br /> CITY al VIvj Cre- 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 BILLING PARTY <br /> y0 OF EMPLOYEES <br /> FACILITY NAME �1�5 ra Pro C r TRUST LANDS? Y / N <br /> FACILITY ADDRESS Lk n is kocLd HOME PH { ) <br /> CROSS STREET RU(SN PH { ) <br /> CITY r�C Y STATE ZIP <br /> CensusBOS Dist location Cade Gity Code --"--"-•' <br /> MAILING ADDRESS APN x 263 110, 2 <br /> CARE OF SIC CODE <br /> CITY STATE ZIP F.IyEE) <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> T FAC STATUS CODE BUSINESS CODE BUSINESS <br /> L <br /> ����t �t.i1N COUNTY <br /> THIRD PARTY BILLING INFORMATION ENV4RONMEN�ANEAJ H <br /> - NAME C I V(C-r :A C fD F �•1�1.U�f xplE PHONE c ) <br /> MAILING ADDRESS Lo �T Al Tl F:Z--vQa BUSH PHONE C sro ) Cr* = <br /> x �9� <br /> CARE OF <br /> vp <br /> CITY j ) IQA)blt-W STATE ZIP <br />