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SAN JOAQUIN OY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H* DIVISION <br /> elc NASTERFILE RECORD INFORMATION FORM EH O1 15 (OWNFAC) Revis 5/16/93 <br /> FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / /__ INACTIVE <br /> Prior Owner <br /> LANDER CONSTRUCTION CHANCE OF BILLING DATE OF BILLING CHANGE / /__ DELETE <br /> OWNER FILE <br /> OWNER f0 CASE X BILLING PARTY Y / N <br /> OWNER NAME v� ��7 /�yy���� r11t`J N(� OWNER HOME PHONE ( 4 )�-qq Z109 <br /> �l�l O1� flN OWNER WRK/SUS PH I I >J 1 1 <br /> OWNER DBA <br /> ADDRESS <br /> CITY PQfJ _ STATE ZIP g5ILL <br /> MAILING ADDRESS <br /> lv <br /> FY CARE OFl <br /> CITY STATE ZIP <br /> A <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY 10 X BILLING PARTY Y / N <br /> OF EMPLOYEES <br /> FACILITY%N /�-{)� I I� T'V IJ Iv y �`-- TRUST LANDS? Y / N <br /> ." FACILITY DDR Tl , I Y�I.-1 rOIZ-ISI {a HOME PH <br /> CROSS STREET BUSH PH <br /> /'t�/-fi <br /> n _ / 21 o g <br /> CITY �1��� STATE CA ZIP `�`� 31,9P <br /> Census •-••^•'- <br /> BOS Dist Location Code Ctty Code --••••••••- <br /> av <br /> wI _ <br /> APR X <br /> HAILING ADDRESSj�l <br /> M� <br /> CARE OF r I`—fT VY� V 1_..i YlI h NIECE SIC CODE <br /> ,yes, —1 <br /> CITY <br /> _ I�I.P��I _ STATE U_r ZIP ? <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HCME PHONE ( ) <br /> ( ) <br /> MAILING ADDRESS BUSH PHONE <br /> CARE OF <br /> CITY STATE ZIP <br />