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SAN JOAGUIN &Y PUBLIC HEALTH SERVICES ENVIRONMENTAL ON DIVISION <br /> NASTERFILE RECORD INFORMATION FORM EN 01 15 (OWNFAC) Revis 5/14193 <br /> NEW FACILITY CHANGE Of OWNER DATE OF OWNER CHANGE / {� INACTIVE <br /> Prior Ower - <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE DELETE <br /> OWNER FILE <br /> OWNER 10 T / CASE 0 BILLING PARTY T <br /> OWNER NAME a J-QOd S OWNER HOME PHONE ( ) �J <br /> OWNER ORA 1 I��f,,//!!\\V O�y ^Ew1 %K to OWNER WRK/BUS PH C Zro c) 5 3 7 - `J 4 G 6 <br /> ADDRESS i V I �rG./]�f�h,nJ bl LJ Q- -, C� 3.2 <br /> CITY j II'CG(-"� - (r STATE 2IP 1 5 G <br /> MAILING ADDRESShePAar,11D 1 00 dS <br /> J <br /> CARE OF i� r. O1n V\ E-(,5 T{j PC 30X o33,�r1cc !, <br /> CITY 1JQ.V) jet STATE 0-0 ZIP OLJ���- 34/00 <br /> BUSINESS CODE NATURE Of OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY 10 0 BILLING PARTY N <br /> if OF EMPLOYEES <br /> FACILITY NAME I��,v. LS TRUST LAWS? Y / N <br /> FACILITY ADDRESS 2(- �//4k� �0.L,M,.r QC-1U-Z WHE PH ( q ) <br /> CROSS STREET Ly a A��V`O , j ma PR ( %09 ) 73 526 <br /> CITY rGG STATE D ZIP <br /> Cmsua --------- I SOS Dist Location Code City Code ---------- <br /> MAILING ADDRESS APN t <br /> GRE 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 HC ME PHONE ( ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> CARE OF Page IOA. <br /> CITY 40 STATE ZIP 0 I <br />