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S" "QUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> P'•ASTERFILE RECORD INFORMATION FORM EH 01 15 (G.NFAC) Renis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER <br /> DATE OF OWNER CHANGE /_ / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> [OW:N:E:R ID O CASE # BILLING PARTY Y / N� <br /> OWNER NAME Lri2it Q H I 14C OWNER HOME PHONE ( ) <br /> C � Sc�� v�9 0�. <br /> OWNER DBA 2 OWNER WRK/BUS PH <br /> ADDRESS <br /> CITY l STATE Cl <br /> ZIP I� <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 1 <br /> / # <br /> OF EMPLOYEES <br /> FACILITY NAME !S cC vrx CU "� a uTiI�J$T LANDS? Y /0 <br /> FACILITY ADDRESS / w1j' BF.�� Qln-��j�.' (�J✓C c HOME PH <br /> L � C ) <br /> CROSS STREET BUSN PH <br /> CITY G l STATE ZIP <br /> Census --------- SOS 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 �—f—�- <br /> NAME /(/�� {_�YZ�/1J L/ C'' l HOME PHONE (1 ) <br /> MAILING ADDRESS _ of (Ii-C L BUSN PHONE <br /> CARE OF f / Page IDA <br /> CITY ��. /lam-(Z STATE 4 ZIP 9y -J <br />