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SAN JOACUIW CC PUBLIC HEALTH SERVICES • ENVIR0101ENTAL NEA IIVISION <br /> NASTERFILE RECORD INFORMATION FORM EN 01 15 (WNFAC) Revis 5/1:/43 <br /> NEW FACILITY CHANGE OF OWNER DATE OF WRIER CHANGE / /_ I INACTIVE <br /> Prior Omer <br /> UNDER CONSTRUCTION CHANCE OF BILLING DATE OF BILLING CHANGE / /_ IOELETE <br /> OWNER FILE <br /> OWNER ID ]JJ� - CASE s I �.J� <br /> BILLING PARTY I 7 / �� <br /> OWNER NAME 515 3/pC;,r(tF Q- OZER Hoe PHONE C ) <br /> OWNER DBA .5m-5 ,�„/I✓C`/L I S �r•<V��rE 06UER WRL/BUS PH (10) <br /> ADDREC[/ <br /> SS � T s� r r-+F / I JCCQC.ETE/� <br /> CITY - Du�,� � STATE rl ZIP t 2-o 10 <br /> NAILING ADDRESSwd <br /> CARE OF / '[/C �I•G )'L-,2) 56et,5 <br /> of <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OXER BIA INESS <br /> FACILITY FILE <br /> FACILITY ID s �,, I BILLING PARTY <br /> M c ! OF EMPLOYEES <br /> FACILITY NAME I—�7l 7 (1_,_iL TRUST LVIDS? Y / N <br /> FACILITY ADDRESS I� ` C- 1 HCME PH C AL <br /> CRCSS STREET c (-)09 ZIP G� BUSK PH f ) <br /> CITY WIJ C_ SATE (-) 1 ZIP l•� � <br /> Census I •--•-•••- I BOS Dist I I Location Cade 9 9 City Code ----_•••.__ I <br /> NAILING ADDRESS APN x /b'3 • /yo Od • �o _ <br /> CARE OF 14/e yo1- � S064,3 sic CODE <br /> CIT( STATE ZIP <br /> GENERAL TYPE of 3USINESS at this FACILITY <br /> JST FAC STAN COCE I I 3USINESS CCOE I I SUStNESS TYPE (IAT) <br /> THTRD DARTY 3I1,L 14G INFCCRMA77CN <br /> ,NAME 4CME PHGME C ) <br /> MAILING ADDRESS 3USN P4CNE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />