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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) Revis 5/14/93 <br /> :\ <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / /_ INACTIVE <br /> Prior Rorer DELETE <br /> 1 UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE <br /> OWNER FILE <br /> OWNER ID 3�t �� <br /> CASE # BILLING PARTY Y / N <br /> OWNER NAME �0 l�� � "—'--�� 0.�' �— O"ER HOME PHONE ( ) <br /> OWNER WRK/BUS PH ( ) <br /> OWNER DBA <br /> ADDRESS <br /> CITY <br /> UYl STATE C�•{"I ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> BILLING PARTY Y / I N. <br /> FACILITY ID # <br /> # OF EMPLOYEES C5 <br /> TRUST LANDS? Y / �N <br /> - FACILITY NAME <br /> HOME PH <br /> FACILITY ADDRESS <br /> BUSH PH ( 209 0 y <br /> CROSS STREET <br /> CITY STATE Com, . ZIP <br /> Census BOS Dis[ <br /> LocationCode City <br /> A_ f� APM # QoPV �'•07D — d1I <br /> MAILING ADDRESS2 <br /> � . (( C9 Y I -� �0. -e�- ` SIC CODE <br /> C1'Cc <br /> -I�.YDY CARE OF <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE <br /> BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> / HOME PHONE <br /> NAME ��f LNV/N�/N /�7� LI,MIcX/-y �/�•S LSC ( ) <br /> MAILING ADDRESS <br /> � 1a20 BUSN PHONE ('169 <br /> CARE OF vv r <br /> yrppp q � . <br /> CITY / "vVy�/� STATE �� ZIP 713 <br />