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SAN JCAQUIN COUNT PUBLIC HEAL'T'H SERVICES - ENVIRONMENTAL H)t's DIVISION <br /> MAST-RFILE RECORD INFORMATION FORM 01 15 (OWNFAC) Revis 8/26/93 <br /> 1 <br /> INACTIVE <br /> g+ NEW FACILITY 03-AME OF OWNER DATE OF OWNER CHANGE <br />�L Prior Owner <br /> ` <br /> CHANGE OF BILLING DATE OF BILLING UNDER CONSTRUCTION <br /> CiWGE / / DELETE <br /> OWNER FILE <br /> n.- <br /> CASE # BILLING PARTY Y / N <br /> OWNER ID ( . <br /> OWNER NAME T \ '1 O O 1 a ' ` OWNER HOME PHONE ( ) <br /> OWNER WRK/BUS PH (ILL) LI b 7 - 6_305._ <br /> s. OWNER DSA <br /> r: <br /> -I 0 <br /> OWNER ADDRESS <br /> sOWNER CITY 5 (G C Il r o STATE c _ ZIP I D 6 <br /> MAILING ADDRESS f Q <br /> t <br /> J, <br /> CARE OF <br /> T.; <br /> STATE ZIP <br /> CITY <br /> i <br /> BUSI.NESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> BILLING PARTY Y / <br /> k. FACILITY ID # <br /> T• <br /> OF EMPLOYEES <br /> 5 G a 5 + � r O ��✓� TRUST LANDS? Y / N <br /> FACILITY NAME <br /> z FACILITY ADDRESS <br /> 7 0 l C.f,�Q Y < Vag PH <br /> HOME ( ) - <br /> C Lt u 51 1--t t BUSH PH ( ) <br /> CROSS STREET J''Ct �l 1 S <br /> CITY 5 7 0 C h l o✓1 STATE �_ ZIP q y ;- a 6 <br /> Census --------- BOS Disc <br /> Location Code City Code ----------- <br /> MAILING ADDRESS ' E - C 4, `VIP K , q\/ APN # <br /> CARE OF q ` QOO�j O 1 kSIC CODE <br /> [;0G61 I d� STATE C ZIP q / �06 <br /> CITYS7q io(n <br /> GE"7ERAL TYPE of BUSINESS ac this FACILITY (>a5 <br /> a_ BIISZNESS CODE BUSINESS TYPE (IIST) <br /> OST FAC STATUS CODE <br /> THIRD PARTY BILLING INFORMATION <br /> _ HOME PHONE ( ) <br /> NAME <br /> BUSN PHONE ( ) <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br />