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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHARGE / / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE a" <br /> CASE # BILLING PARTY Y / <br /> OWNER NAME✓ I�J�T1�oNv F Som ZR AN-� OWNER HOME PHONE ) 8 35'' 3330 <br /> OWNER DBA ✓ OWNER WRK/BUS PH (✓ ) <br /> ADDRESS ✓ /O S 6 T� SL <br /> CITY .� 1 t^c7GV STATE✓ �A ZIP ✓ ?�7,4 <br /> —�— Jt- <br /> MAILING ADDRESS✓ Sq�►1� <br /> CARE OF <br /> CITY ✓ STATE J ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # % BILLING PARTY Y / Q <br /> OF EMPLOYEES <br /> FACILITY NAME = 1 TRUST LANDS?? Y / N <br /> / U v D <br /> FACILITY ADDRESS jpF Co Jrf FAd Q� V �A/NPS • _ TrQ�Y HOME PH (J) <br /> CROSS STREET✓ I) 2-3; '84�0 0 BUSH PH <br /> CITY STATE C ZIP <br /> Census --------- BOS Dist Location Code City Code ---------- <br /> MAILING ADDRESS APN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP D <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS MOE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION 'f�/ a -44K <br /> NAME �I t r q P i Sal�Z SoN�A /{PA � t/PJP��O V?lt/ HOME PHONE ( ) <br /> MAILING ADDRESS �n IaT� ST BUSH PHONE (ZOQ <br /> CARE OF p <br /> CITY TfaV STATE �4. ZIP / �� ?� <br />