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14. <br /> SAH .fOACUIk CpUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> I(AST£RF1LE RECORD INFORMATION FORM EH 91 15 (OWNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / f INACTIVE <br /> Prior Omer _ _ L <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE j / / � DELETE <br /> J ' OWNER FILE <br /> OWNER ID ® /U CASE BILLING PARTY Y / 017 <br /> OWNER NAME OWNER HOME PHONE ( ) <br /> OWNER DBA OWNER WRK/8US PH ( �G ) y <br /> ADDRESS lz <br /> CITY STATE �J� ZIP <br /> �_. <br /> MAILING ADDRESS <br /> i <br /> i <br /> CARE OF gz�± <br /> CITY STATE ZIP C <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE " <br /> FACILITY ID # �O I BILLING PARTY Y / If <br /> j0 OF EMPLOYEES <br /> FACILITY NAME 1- TRUST LANDS? Y / H <br /> FACILITY ADDRESS d /� C OME PH t 3 <br /> CROSS STREET r BUSH PH ( ) <br /> CITY T-�/'/� /�. „ STATE ZIP <br /> =Census -...-- SOS Dist Location Code l Ci#y Code MAILING ADDRESS ADDRESS ! �� , '{ n2� APN * zz, Q b <br /> CARE OF a SIC CODE <br /> CITY � --T� STATES ZIP S� <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CSE BUSINESS CODE " BUSINESS TYPE (UST3 <br /> THIRD PARTY BILLING INFORMATION I <br /> f/ <br /> NAME HOME PHONE ( ) <br /> .i <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> CARE OF i Page ]OA <br />' CITY STATE ZIP <br /> :i <br />