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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) ReVis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / /__ INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE <br /> OWNER FILE <br /> OWNER 10 CASE # BILLING PARTY <br /> OWNER NAME C l7 S7z;lc.IC TyeJ OWNER HOME PHONE C ) <br /> OWNER DBA OWNER WRK/SUS PH (_)cc- J 32 c7 <br /> ADDRESS 3o S N E <br /> CITY STa CK TDrN STATE C?`� ZIP 15.2 0 2— <br /> MAILING <br /> MAILING ADDRESS <br /> CARE OF O� �i'�i-tM(*JIS I <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS "u 0-�k c I P A k'f <br /> FACILITY FILE <br /> FACILITY ID # -� ��� BILLING PARTY Y / O <br /> I/ T # OF EMPLOYEES <br /> FACILITY NAME 1�'I,CVAL ,((/1 P1 LE 1/ I CQ EN�N C1411P / y-'N Pl fit_ TRUST LANDS? Y / N <br /> FACILITY ADDRESS Y C K� JJ Ll=1/ I FKE"cH C4viP TL),QNP)KC HOME PH (�_) <br /> CROSS STREET BUSH PH ( ) <br /> CITY ��TOG K'Td"\J STATE CrC ZIP <br /> Census --------• SOS Dist Location Code City Code ----••----- <br /> MAILING ADDRESS APN # 16, S-2 <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 <br /> NAME HCME PHONE ( ) <br /> MAILING ADDRESS BUSH PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />