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SAN .10AQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIROl1fSENTAL HEALTH DlVISiON <br /> MASTERFILE RECORD INFORMATION FORM EN 01 15 (CWNFAC) Revis 5/14/93 <br /> NEW FACILITY x 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 /> FED r L CASE 70 BILLING PARTY L21 N <br /> a <br /> OWNER NAME ✓C"h V OG t�In �Ot�4. P 0WNER HOME PHONE C ) <br /> OWNER 08A re`I� kee fie,! 0WNER WRK/BUS PH ( ZOJ_) �IGt - ZI$y <br /> 50o►�oa� 1r <br /> ADDRESS ZZ-L t7AST IA3IL6,P-1 e-Vib.e— <br /> CITY (� STATE ZIP 520 <br /> MAILING ADDRESS S I7 L <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # J <br /> BILLING PARTY Y / N <br /> 'f>CA.%Il OC EE <br /> "0 l 0 OF EMPLOYS <br /> / <br /> FACILITY NAME 2e-hef=-1 1/S�O�fi�� y ___ TRUST LANDS? Y / N <br /> FACILITY ADDRESS 5 0 0 4v 5 HOME PH ( ) <br /> CROSS STREET 7 YDBUSH PH (2b9 ) <br /> CITY STATE ZIP <br /> Census --------- SOS Dist Location Code City Code ---------- <br /> MAILING ADDRESS �" E' er APH 9 <br /> CARE OF Cael f L` SIC CODE <br /> CITY <br /> '}5yr)ck4-6 STATE U1'J ZIP "L -2 - <br /> GENERAL TYPE of 9USINESS at this FACILITY <br /> LL <br /> AC STATUS CODE 3USINESS CCJE BLS(NESS TYPE (UST) <br /> THIRD PARTY BILLING :NFORMATICN <br /> IN <br /> NAME ✓GIMQ /7S DHCHE PHCNE ( ) <br /> MAILING AZCRE:'S BUSH PHONE ( ) <br /> CARE OF Page I�A <br /> CITY STATE ZIP `"f <br />