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Ivor <br /> 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 <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE �/_2 ! 3 DELETE <br /> OWNER FILE <br /> OWNER ID CASE # BILLING PARTY Y J O <br /> OWNER NAME OWNER HOME PHONE ( JJ } <br /> OWNER DBA OWNER WRK/BUS PH (UQ te}J(�� - 99&+ <br /> ADDRESS I7,lO09 N <br /> CITYSTATE ZIP % :521 <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / N <br /> # OF EMPLOYEES <br /> FACILITY NAME TRUST LANDS? Y ! N <br /> FACILITY ADDRESS HOME PH t ) <br /> CROSS STREET BUSH PH ( } <br /> CITY STATE ZIP <br /> Census --------- BOS 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 �/12DC /It Ldte/ HOME PHONE C ) <br /> MAILING ADDRESS %VU 1 d� �! BUSH PHONE <br /> CARE OF <br /> CITY STATE L4 L ZIP <br />� l <br />