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SAN 4OAQUIN441NTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL LTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EN 01 15 (OWNFAC) Revis S/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 / / DELETE <br /> OWNER FILE <br /> OWNER ID CASE # BILLING PARTY Y / N <br /> OWNER NAME T-? rI! I^ ( '' I i�l(,r� OWNER HOME PHONE <br /> OWNER OBA � { � r _?�1,' �C t"i}�''�'• OWNER URK/BUS PH (!:E <br /> ADDRESS <br /> n <br /> CITYy", - -... STATE ZIP <br /> HAILING ADDRESS <br /> CARE OF <br /> 4 <br /> CITY STATE ZIP <br /> r} <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / N <br /> r # OF EMPLOYEES Fy7 <br /> FACILITY NAME 1 �� f ( r1`tt,'W �r . c"s'(r:�J {�"i( C'� TRUST LANDS? Y <br /> FACILITY ADDRESS :��y? .l{�c SIG'( I'?(� �— HOME PN <br /> CROSS STREET +—� r.- (� 7� i _ BUSH PH ( ) r�T;;r 1s�`1. <br /> C' <br /> CITY C 1�' (-a STATE {. `7 ZIP / � <br /> Census --------- SOS Dist Location Code City Code -"-•" <br /> i <br /> HAILING ADDRESS rrJ�!"r,. %� C l:C�I:T C I^ APN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY 6-741- "•�'ctt ='�%.c(''�� <br /> W".TUS r r_ BUSINESS ccDE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMA <br /> TION <br /> NAME /l_�![?���CI' {'� __ ROME PHONE ( <br /> J3. � <br /> ( � <br /> I _ BUSH PHONE ( 11c/ <br /> CARE OF � h �� S r ii }�?.'r„� - Page <br /> CIT( �.r' '•( STAIE �r(. ZIP � zi�/f.' <br />