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SAIL JOACU19 COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION ` <br /> MASTERFILE RECORD 11IFCRMATIOH FORM EH 01 15 (C"FAC) Revis 5/16/9; <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING ~DATE OF BILLING' CHANGE / / DELETE <br /> OWNER FILE <br /> KEA :0 "]� ' L CASE 0 BILLING PARTY <br /> CEJ a <br /> OWNER NAME ✓GUVN 73OG 1n n �Otny� , P j OTHER HOME PHONE C ) <br /> CWWER DBA �'2�e. ke.P-def � � NIIER WRIU9US PN ( Z- o�) `!(s _ zI$cD <br /> Co,.v, Co- , 1 PAs rVl ar1�-^ <br /> ADDRESS �Z� GS wc6yp f Q.y1,n� J `, <br /> CITY STATE _ 2IP l 520X <br /> MAILING ADDRESS 17 f"( E <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY IDR BILLING PARTYJ— Y / H <br /> 50.v,3 00. r 9 Of EMPLOYEES <br /> FACILITY NAME 6e,ner�A TRUST LANDS? Y / H <br /> FACILITY ADDRESS `500 5�, � �., NONE PH (-� ) <br /> CROSS STREET + h $ �G BUSH PN (-b 1 ) 112 <br /> CITY STATE ,C ,_„^ ZIP <br /> y�} Census --------- BOS Dist Location Code City Code <br /> ` MAILING ADDRESS ,/► J; We-6e.1— 4- -,i,, V-7 APR 9 <br /> CARE OF 3� r �1 GQr _i � S SIC CODE <br /> CITY (_.UC '0 ^- STATE ZIP <br /> GENERAL TYPE of 9USINESS at this FACILITY <br /> =U-STAC STAIUS CODE BUSINESS CCJE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING 'NFORMATION y <br /> /� \� <br /> HARE Yh Q T7S Qc..)Y�e,.r _ HOME PHONE <br /> t <br /> MAILING ACCRESS BUSH PHCNE ( ) <br /> CARE OF (/ Page JOA <br />