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�. SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL EALTH pllf[SEH 01 15 (OWNFAC) Revis 8/26/93 <br /> MASTERFILE RECORD INFORMATION FORM <br /> DATE OF OWNER CHANGE INACTIVE <br /> NEIL FACILITY CHANGE OF OWNER i <br /> Prior Owner DELETE <br /> r UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE �� <br /> OWNER FILE <br /> 1 <br /> CASE # BILLING PARTY Y / N <br /> OWNER ID � <br /> I <br /> I <br /> OWNER HOME PHONE ( ) <br /> OWNER NAME ki <br /> OWNER wRK/BUS PH (1_/& ) <br /> ) <br /> OWNER DBA <br /> F OWNER ADDRESS 10 <br /> OWNER CITY <br /> STATE`—�' ZIP <br /> MAILING ADDRESS <br /> l <br /> CARE OF <br /> } CITY STATE 21P , /S 1 <br /> 14 <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE i. <br /> FACILITY ID # j BILLING PARTY <br /> OF EMPLOYEES <br /> FACILITY NAME TRUST LANDS? Y / N <br /> I <br /> FACILITY ADDRESS I cn s _ HOME PH ( ) <br /> � C��C( <br /> CROSS STREET -- BUSN PH (✓&+ )�Z <br /> CITY STATE L/r I ZIP <br /> s <br /> # Census -------- SOS Dist Location Code'. j City Cade ---------' <br /> MAILING ADDRESS I APN # <br /> i <br /> CARE OF Sic CODE <br /> i <br /> CITY STATE ZIP U <br /> # GENERAL TYPE of BUSINESS at this FACILITY <br /> k <br /> F <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME- I HOME PHONE ( ) <br /> i} <br /> M MAILING ADDRESS Ij BUSN PHONE ( ) <br /> i <br /> k CARE OF 2^i <br /> CITY STATE ZIP <br />