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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H�iH DIVISION <br /> HASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 5/14/93 <br /> n` <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> R UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> OWNER IDCASE # BILLING PARTY Y / O <br /> OWNER NAME '�►„r1�I ; _ OWNER HOME PHONE <br /> OWNER DBA –" <br /> OWNER WRK/BUS PH ( _) 2 ' 'MIA <br /> ADDRESS A1-11 AICL-1 b E <br /> CITY r 1 p� ��f��_.. STATE �_ ZIP <br /> M <br /> MAILING ADDRESS �[ <br /> CARE OF 9 <br /> CITY <br /> STATE ZIP O� <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br />> I <br /> FACILITY FILE <br /> i FACILITY ID # �G BILLING PARTY Y / <br /> # OF EMPLOYEES -20 <br /> FACILITY NAME 1 TRUST LANDS? Y 10 <br /> FACILITY ADDRESS _ <br /> 'I" + L_ • l H 1 rn Lan�Lci HOME PH <br /> r <br /> CROSS STREET YY�YL1 [f 1 - 131 �Y i _ q r} BUSN PH { ) <br /> CITY 1f[ STATE ^ 2IP l�L. <br /> ` Census 80S Dist Location Code City Code ------'---- <br /> MAILING ADDRESS i C ( 1 APN # <br /> CARE OF SIC CODE <br /> w CITY STATE — ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> T141RD PARTY BILLING INFORMATION <br /> �_+�/+ <br /> NAME f ���t�I f A/ C 1 c k I �f I l I __ HOME PHONE C ) <br /> MAILING ADDRESS — l.gt��l�1P. BUSN PHONE _)�Q�- 2ioS_ <br /> CARE OF . m I f A%If [!,i , <br /> CITY MI1 lMn JI' A)_. _ STATE _ ZIP <br />