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SAN JOAQUIN A PUBLIC HEALTH SERVICES - ENVIRONMENTAL HER DIVISION <br /> NASTERFILE RECORD INFORMATION FORM EN 01 15 (ONNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / /_ INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANCE OF BILLING DATE OF BILLING CHANGE / 2 /�` DELETE <br /> OWNER FILE /Q <br /> OWNER ID - C?�l� CASE # BILLING PARTY Y <br /> OWNER NAME Q O✓1 h3D FOd S OWNER HOME PHONE <br /> OWNER DBA I IfV D�vj-% /n�E ,1 �K h OWNER WRK/BUS PH ( Soo ) 5 3 7- y G 6 <br /> ADDRESS 2401 / If G./'J�CTh.nf 1)l LV Q. <br /> CITY � '`A C- STATE ZIP 15L1(J <br /> MAILING A000.ESS �. � �.C'1i4r1D 1 OC7OS [� u <br /> CARE OF I I (. ,ONv� �(,S LV�u� P. 13O 7C 1123no !l <br /> CITY �eh JZ.f STATE `--D ZIP 10 A1 '7- 3y�L/ <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE S <br /> FACILITY ID # � BILLING PARTY <br /> I # OF EMPLOYEES <br /> FACILITY NAME ep✓ v`C� �OC7IS TRUST LANDS? Y / N <br /> FACILITY ADDRESS 299) I Mas-I /7//I�L ITl lr.�(�/� �CLJV-f HOME PH ( ) <br /> CROSS STREET 6cc"� �Ly\ e- G- t✓` 2BUSH PH ( 70q <br /> I ) '335- J02(, <br /> CITY rGG STATE CA ZIP <br /> Census'' II --------- BOS Dist "'�Loocation Code City Code -•--------- <br /> MAILING ADDRESS 2`�l Q � Olc X4bu ALJ ��J-e-- APN # <br /> CARE OF pp� l//''6rr—c 1q roc S SIC CCOODE <br /> CITY I ac`'I STATE l../ 1 ZIP �J <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> =UST STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> MAILING ADCRESS BUSH PHONE ( ) <br /> CARE OF Page IDA <br /> CITY STATE ZIP 44 <br />