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SAN JOAQUIN 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 CHANGE / / INACTIVE <br /> Prior Owner Gz <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE DELETE <br /> OWNER FILE <br /> OWNER IO t CASE # BILLING PARTY / N <br /> OWNER NAME OWNER HOME PHONE ( p <br /> OWNER DBA /,�{�/l OWNER WRK/BUS PH (V_) ��LJ- 9m <br /> � <br /> ADDRESS LZ 09 Al. ALV <br /> CITY �� T STATE ZIP 952-4-ZD <br /> MAILING ADDRESS <br /> i CARE OF ,V(" <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / <br /> # OF EMPLOYEES <br /> FACILITY NAME (� TRUST LANDS? Y / N <br /> FACILITY ADDRESS 7`� HOME PH ( ) <br /> CROSS STREET IA- / BUSH PH ( ) <br /> CITY LI& Q� STATE UP ZIP / : ZD(O <br /> Census --------- <br /> BOS Dist Location Code O City Code ----------- <br /> MAILING ADDRESS APN <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> --T- <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE <br /> MAILING ADDRESS BUSN PHONE <br /> CARE OF s - <br /> CITY STATE ZIP <br /> L. <br />