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SAN JOAQUIN C,astY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (CWWFAC) Revis 5/14/93 <br /> 7TY CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> TRUCTION CHANCE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> ------------ <br /> OWNER ID B A LING PARTY / N <br /> i <br /> OWNER NAME OWNER HOME PHONE ( ) <br /> OWNER DBA / OWNER WRK/BUS PH ( ) <br /> ADDRESS <br /> CITY 7(,UJ+ A-�D�,✓ STATE /L/� ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> j � BILLING PARTY Y / (N <br /> FACILITY ID # <br /> # OF EMPLOYEES <br /> FACILITY NAME TRUST LANDS? Y / N <br /> FACILITY ADDRESS HOME PH ( ) <br /> CROSS STREET /_BUSH PN ( ) <br /> CITY �lh1Cn�'y►� STATE � ZIP 9��(! <br /> Census BOS Dist Location Code �'1 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 NST) <br /> THIRD PARTY 3ILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS BUSN PHONE C ) <br /> CARE OF <br /> CITY STATE ZIP <br />