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SAN JCAOUIP.'9rXNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HErilll DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 5/14/93 <br /> NEW FACILITY / CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> OWNER ID L J CASE # BILLING PARTY Y / N <br /> OWNER NAME \n q) OWNER HOME PHONE ( ) <br /> OWNER DBA OWNER WRK/Bl1STPH I ) <br /> ADDRESS <br /> CITY ^ (� STATE ZIP -- <br /> MAILING ADDRESS D ' F/��� O-ff/ 7 q <br /> CARE OF !/�/1/I[ J /�,y�)� �GJX �i/��J <br /> CITY #(Oy STATE /'I zip <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID R / '�//�7 /J/////,,� I ///J BILLING PARTY Y / N <br /> FACILITY NAME /�(�!/// 0'�%/ -r" # OF EMPLOYEES <br /> TRUST (ANDS? Y / N <br /> FACILITY ADDRESS (J �" U� �X,— HOME PH ( ) <br /> CROSS STREET BUSH PH ( ) <br /> CITY L�r�, STATE ZIP <br /> Census --------- SOS Dist Location Code City C�oldte//�----------- <br /> MAILING ADDRESS APN # yT7 CARE OF OF SIC CODE <br /> CITY STATE 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 HOME PHONE ( ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />