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SAH JOAQUIN IY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H,.,�H DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / 0 / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE /_ / DELETE <br /> OWNER FILE , <br /> OWNER ID CASE # BILLING PARTY (12 <br /> / N <br /> OWNER NAME LJ� f�I W-kO OWNER HOME PHONE ( ) <br /> OWNER DBA r OWNER WRK/BUS PH <br /> ADDRESS P P� 1 ! <br /> CITY I)U P L-R STATE ZIP 6L <br /> MAILING ADDRESS <br /> 1 <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / N <br /> 1 <br /> # OF EMPLOYEES <br /> FACILITY NAME f TRUST LANDS? Y / N <br /> ii FACILITY ADDRESS '? �-!�1} . HOME PH <br /> 1 <br /> CROSS STREET BUSH PH f ) - <br />;,i /+ It <br /> CITY STATE I-,iF7 ZIP <br /> s <br /> Census -- 80S Dist Location Code a City Code <br /> MAILING ADDRESS APN # <br /> 4 <br /> CARE OF SIC CODE 4 <br /> i <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODEI F <br /> BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE C ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br /> I <br />