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S�JCAQUJN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION _ <br /> -' NASTERFILE RECORD INFORMATION FORM <br /> NEN FACILITY EH OT 15 (O;JNFAC <br /> CHANCE Of OWNER ) Rwlt 5/16/9; <br /> Prior 0,,, DAIE OF CNNER CHANGE <br /> UNDER CONSTRUCTION /- <br /> CHANGE OF BILLING INACTIVE <br /> DATE OF BILLING CHANGE <br /> DELETE <br /> - OWNER FILE <br /> O"MER ID <br /> CASE X <br /> BILLING PARTY Y // N <br /> OWNER RARE <br /> i <br /> DNNEp DBA <br /> W` OWNER HOME pH.CIIE <br /> ADDRESS X75-��---(-�--1� SER NRK/BUS PH (1 ol r- 1 <br /> clTr ,yam <br /> RAILING TATE <br /> ADDRESS ZIP <br /> 5 <br /> CARE Of <br /> nrr — rrs,., �. <br /> � STATE - ZIP <br /> BUSINESS CODE <br /> NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY 10 X Q <br /> BIIUNC PARTY Y <br /> FACILITY RARE L �. <br /> { 1 Cl .(,1)t l X OF EMPLOYEES <br /> FACILITY ADDRESS J�� �Vf` TRUST LANDS? Y / N <br /> � - <br /> CROSS STREET- HOME PH < ) <br /> I � <br /> CITY { L,L� ..�� ? BUSH PH ( ) <br /> STATE A Zip (.�7((o <br /> Census --------- DOS 01st <br /> Location Cade CItY Code <br /> MAILING ADDRESS <br /> �I <br /> CARE OF APN X <br /> CITY <br /> SIC CODE <br /> _ <br /> STATE `-'�L ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE <br /> BUSINESS CODE <br /> THIRD PARTY{BBIILLING�T I= BUSINESS TYPE (UST) <br /> NAME l.._ �lloit) /k-"- ()^ -(I— <br /> MAILING <br /> MAILING ADDRESS HCHE PHONE ( ) . <br /> CARE OF <br /> _ / BUSH PHONE <br /> f".0>^/ <br /> STATEf!�/�- ZIP \ t._ <br />