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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EN 01 15 (CYNFAC) Revla 5/14/93 <br /> NEW FACILITY CHANDE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior ONnar <br /> UNDER CONSTRUCTION CHANCE OF BILLING DATE OF BILLING CHANGE / /__- DELETE <br /> OWNER FILE <br /> OWNER ID ! S CASE tl BILLING PARTY Y / N <br /> OWNER NAME MR. JOHN E. DONAVAN OWNER HONE PHONE ( ) <br /> OWNER OBA OWNER WRK/BUS PH ( ) <br /> ADDRESS 2256MST ELM STREET SUITE C <br /> CITY LODI STATE CA ZIP 95240 <br /> MAILING ADDRESS SAMD <br /> CARE OF <br /> CITY STATE IIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE - <br /> fACILITY 10 tl -` r7 - BILLING PARTY Y / N <br /> l � Qti Y OF EMPLOYEES <br /> FACILITY NAME NOT CURRENTLY OCCUPIED i/QnQ h Pro� r �-./ TRUST LANDS? Y / N <br /> FACILITY ADDRESS 804 AND 810 EAST BLACK DIAMOND WAY HONE PH ( ) <br /> CROSS STREET NORTH BECKMAN ROAD BUSH PH ( ) <br /> CITY LODI STATE CA ZIP PAYMEW <br /> census ....... <br /> BOS Dlst lacatton Coda City Code -••---•-•-- <br /> P R 2 1996 <br /> ,i UI JNTY <br /> MAILING ADORESS APN M __ 049-170-22w rni it u4rm Tu SE VICES <br /> 04VIRONMENTAL HEALI H DIVISIC <br /> CARE OF SIC CODE <br /> CITY STATE IIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC 3TI.11. .00E BUSINESS CODE BUSINESS TYPE (UST) <br /> INIAD PARTY BILLING INFORMATION Z A-)V -7 /dJ9 <br /> NAME V PU4_,AL- 'l HONE PHONE ( ) <br /> MAILING ADDRESS P'o' bo)( i549 BUSH PHONE ( ) <br /> GRE OF f Page IOA <br /> CITY -.J- fl.�.�� STATE <br />