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IOM <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERvIckS • "Ylltp £MTAL HCALTH DIVICE Ot 15 (OWNfAC) R#II 5/14/93 <br /> MASt£RFiIE RECDRO INFORMATION FORM <br /> CHANGN11ER E OF C �,_„«.. <br /> DATE OF OWNER CHANGE —l�_,J-� INACTIVE <br /> NEv FACILITY <br /> prior OmerDELETE <br /> UNDER CANSTRUCTION <br /> CHANGE OF BILLING DATE Of BILLING CHANGE <br /> OWNER FILE <br /> .............. <br /> CASE BILLING PARTY Y <br /> C�LIER 10 _ <br /> OWNER NOME PHONE (O�;�) �•s. 3 <br /> Out1ERNAME t S^3r <br /> OWNER WRK/AUS PH — <br /> OWNER DBA !V <br /> ADDRESS <br /> f` � STATE 2I1• „ � QO � <br /> CITT PAYMENT <br /> MAILING ApOR£9 r y ' e-1— *1 + 1993 <br /> CARE OF AN JOAQUIN COUNTY <br /> xIP G HEALTH SERVICES <br /> starE <br /> CITY _ Elk QNMENTAL HEALTH DIVISION <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> 91LLINO PARTY Y / 0 <br /> fAC1LiTY !D N <br /> $ OF EMPLOYEES <br /> - TRUST LANDS? Y / N <br /> FACILITY NAME <br /> FACILITY ADDRESS _13 'A .3— --..� <br /> BUS” PN <br /> CROSS STREEt 1 <br /> (� P•yY�.p� STATE zip <br /> CITY -- <br /> city Code .......... <br /> Census ----••• SOS Ols� Location Code , <br /> . ... .nom <br /> APR N <br /> MAILING ADDRESS <br /> SIC CODE 4'z <br /> CARE OF <br /> CITY STATE .w ZIP <br /> GENERAL TYPE of BUSINES$ 6t this FACILITY Z <br /> U5T FAC STATUS CODE <br /> DU41Hkcc coon eunixc�a tr � <vct) <br /> r RO 9ARTY BILLING INFORMAi1ONf' <br /> NOME PHONE (_ 1'V �5�' 1 " a) tr <br /> NAME /}� <br /> "" ETUSN PHONE ( )„ ....�....► <br /> MAILING ADDRESS <br /> CARE OF <br /> ,.. �� �Ci`� STATE �.. ZIP L "' <br /> �-O .1 t7T92T.Sb0T.2T. T 01 J.10NA 4Id2T ttb0 r,66T•-42-0 <br />