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SAN JOAQUIN ANY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 8/26/93 <br /> NEW FACILITY _ CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> OWNER ID CASE # BILLING PARTY Y / N <br /> OWNER NAME OWNER HOME PHONE ( ) <br /> OWNER DBA Theyj t rl e Groy r '}�7������ OWNER WRK/HUS PH ( 2C)l )5 / - I <br /> OWNER ADDRESS I C)C) U IGU <br /> OWNER CITY �� STATE —1 1 ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> r <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / N <br /> Ihti W l � n L rO J2 # OF EMPLOYEES <br /> FACILITY NAME `+G TRUST LANDS? Y / N <br /> FACILITY ADDRESS ��c> L j Vy Y �L� HOME PH <br /> -CROSS STREET BUSN PH ( ) ��- �_ <br /> �� 11 CITY R O' 1 STATE CA ZIP <br /> i <br /> =C,,Is"" --------- BOS Dist O 0 5 Location Code City Code ----------- <br /> i <br /> i <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 <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS p` BUSN PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP 'I <br />