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SAN JOAQUIN PY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEOR DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / /_ INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / /_ DELETE <br /> OWNER FILE <br /> OWNER ID 3 I�K CASE,(#/�j BILLING PARTY Y / <br /> OWNER NAME �U ` �"v` I - OWNER HOME PHONE ( ) <br /> OWNER DBA OWNER WRK/BUS PH ( ) <br /> ADDRESS <br /> CITY Q I-�- STATE � ZIP <br /> MAILING ADDRESS � �G <br /> ^•^CITY STATE /MID ZIP ZI �d/ <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY 10 # r 7 BILLING PARTY Y / <br /> /--� # OF EMPLOYEES <br /> FACILITY NAME TRUST LANDS? Y / N <br /> FACILITY ADDRESS HOME PH ( ) <br /> CROSS STREET BU(S'NPHPH ( ) <br /> CITY STATE `- , l ZIP <br /> Census --------- SOS Dist Location Code City Code ----------- <br /> MAILING ADDRESS APN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME /( a �V V I- ,1�(' y " I 0O • _ HOME PHONE ( ) ///+++ <br /> MAILING ADDRESS DD- / ✓,7� J�OC/ J BUSH PHONE ( 46 <br /> CARE OF <br /> CITY J�V I V'• ( STATE C t� ZIP C;� <br />