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I SAN JOAQUIN C PUBLIC HEALTH SERVICES • ENVIRONMENTAL HE*DIVISION <br /> NASTERFILE RECORD INFORMATION FORM EH O1 15 (OWNFAC) Rcv;v 5/14/93 <br /> NEW FACILITY <br /> --=CHANGFE <br /> DATE OF OWNER CHANGE / /_ INACTIVE <br /> rUNDER CONSTRUCTIONG DATE OF BILLING CHANGE DELETE <br /> OWNER FILE t <br /> � d3 <br /> OWNER ID <br /> D oO CASE # BILLING PARTY Y / N <br /> OWNER NAME <br /> �- Brno -'�'� �• ��•S . OWNER HOME PHONE ( ) <br /> �/ <br /> 5 OWNER WRK/BUS PH 2-C/ )�'�L <br /> OWNER DBA <br /> IJ� ADDRESS ^ �} <br /> CITY L5 )CIA �N STATE CA ZIP I S S <br /> MAILING ADDRESS <br /> �C f of SfvL�c h ^tet, 0FP46�� 6A,,ks _ Geov*.e CGi <br /> CARE OF �- p Q <br /> CITY S „'� �O� STATE CA ZIP /J��Z -3 <br /> jBUSINESS CODE NATURE OF OWNER BUSINESS <br /> i <br /> FACILITY FILE <br /> n d BILLING PARTY Y / N <br /> FACILITY ID # ll D <br /> R # OF EMPLOYEES <br /> TRUST LANDS? Y / N <br /> FACILITY NAME <br /> FACILITY ADDRESS 3707 .-L F— I JOr-odD S-� 'E_ <br /> HOME PH ( ) <br /> C/�cvfo� /TII�U1 U e BUSH PH <br /> CROSS STREET �- <br /> CITY � <br /> /'-`t C'vG'� STATE t ZIP <br /> =T7=1:;: <br /> Location Code City Code ----"""' <br /> APNI � 7S-ZS -GY)I <br /> MAILING ADDRESS <br /> SIC CODE <br /> CARE OF <br /> n CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAL STATUS CODE <br /> BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME <br /> sHOME <br /> — _ <br /> NAME _/iMl I Y` I�G•((`I" y Z rr (D� HOME PHONE ( ) <br /> l Z6 G G IrA,O/k CS Da-� UL BUSH PHONE (� ) L 02- 2 <br /> MAILING ADDRESS <br /> CARE OF / ,,[[I/',�/ �,7 nn <br /> CITY �,/L(�t-C-ZS ! STATE � ZIP <br />