Laserfiche WebLink
SAN JMOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> HASTERFILE RECORD INFORMATION FORM <br /> EH 01 75 (WNFAC) Revis 5/14/93 <br /> NEN FACILITY L. CHANGE OF OWNER <br /> DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner --- <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE <br /> / DELETE <br /> OWNER FILE <br /> OWNER ID � <br /> BILLING PARTY Y / N <br /> OWNER NAME V1 (I 1 (�� � X <br /> / 1 OWNER HOME PHONE <br /> OWNER DBA OWNER WRK/BUS PH (�7M <br /> ADDRESS <br /> CITY I�I.J�-%L. STATE ZIP 2�(� TAJ <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY <br /> STATE Zip <br /> BUSINESS CODE NATURE OF OWNER BUSINESSn��,aSe� <br /> FACILITY FILE <br /> FACILITY ID # � <br /> BILLING PARTY y / O <br /> FACILITY NAME # OF EMPLOYEESt-,X�) <br /> TRUST LANDS? Y /AN <br /> FACILITY ADDRESS � HOME PH ( ) <br /> CROSS STREET 111CY' <br /> BUSN PH <br /> CITY -Lodi STATE -1 ZIP <br /> Census •------•- 80S Dist location Code <br /> City Code ----------- <br /> MAILING ADDRESS �/ 1 L, APR # <br /> -Mr, <br /> CARE OF \ A (.y � j � A � X SIC CODE <br /> �I�I J <br /> CITY STATE <br /> 21P <br /> GENERAL TYPE of BUSINESS at this FACILITY - (PEEL Yl nf- <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> I <br /> NAME c HOME PHONE <br /> MAILING ADDRESS � <br /> BUSH PHONE (� .zac-1�-iry1!)L� <br /> CARE OF <br /> CITY STATE ��-i--A--- Zip <br />