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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIreli • ENVIRCHMENTAL IICALTH DIVICIOH <br /> MASTERFILE RECORD INFORMATION FORM SH 01 15 COWNFAC) Revis 5/14193 <br /> NEW FACILITY CHANGE OF GAINER , DATE OF OWNER CHANGE � 1� INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING , DATE OF BILLING CHANGE _4 / J DELETE <br /> OWNER FILE <br /> OMER I 3 CASE # BILLING PARTY Y / <br /> -- L9==j <br /> OWNER NAME .�:.>>Owl t- SWC Ztr' cx •, --/ �p_} `r OIJHfR HOME PHONE ( ) <br /> �i� 24 9`I I _ <br /> OWNER DSA OWNER WAX/BUS PH ( ) <br /> ADDRESS • <br /> CITY _/��.iJV STATE 2IP <br /> PAYMENT <br /> MAILING ��AlEf1►ED <br /> U <br /> CARE OF C1 � V►�1 S ) e • N 0 1 1993 <br /> $AN JOAQUIN COUNTY <br /> GI TY _WeAA STATE ziP l_ G HEALTH SERVICES <br /> EN RONMENTAL HEALTH DNIMN <br /> BUSINESS CODE NATURE OF OWNER BUSINESS k'e & I"O`f >A L <br /> FACILITY FILE <br /> �FA-�IIIIY � SICCING PARTY Y / O <br /> # OF EMPLOYEES <br /> FACIL:Ty YAMS —_::, C TRUST LANDS? Y / N <br /> FACILITY ADDRESS _ �1 r � i-1 (] U„ HOME PH <br /> CROSS STREET } SUSN PH <br /> CITY _ r \�'� �m � _ _ STATE ZIP <br /> Census -- 80S Gist Location Code CITY Code ......•. <br /> MAILING AUDRESS APR # <br /> CARE OF SIC CODE <br /> CITY SPATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> L^,T FAC STA'fIS CODE ouotHLcc ccvc suairir ss Tri cT> <br /> THIRD PARTY BILLING ENFO�RMMAATION ]� 2 lr� <br /> NAME s..J(5wo-44O. I� A�fY 4 `_ �-a�V HCME PHONE <br /> KIT <br /> o �r' f <br /> MAiLtNG ADDRESS r V o �+ "��� ark- 9USN PHONE ( 110 <br /> CARE OF <br /> Los STATE cAF ZIP C v_'+ <br /> • Ili iy� �.:,�.=T 'h4� '=�.�T. y age �.; <br />