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5`03-731 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH Ol IS (OWNFAC) Revis 8/26/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / f INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE DELETE <br /> li OWNER FILE <br /> OWNER [D L{a CASE # BILLING PARTY Y / N <br /> OWNER NAME It <br /> OWNER HOME PHONE <br /> OWNER DBA OWNER WRIL/BUS PH ( 9)Ate" <br /> 969Q 99-- <br /> OWNER ADDRESS <br /> OWNER CITY l77 1,v STATE= Z1P <br /> MAILING ADDRESS ' YY♦♦ <br /> • �� <br /> CARE OF <br /> CITY gJ7Ll/� STATE _ ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / N <br /> I # OF EMPLOYEES <br />�I FACILITY NAME p Yl _ Pro�2 TRUST LANDS? Y / N <br /> FACILITY ADDRESS O fl C3 HOME PH { ) <br /> I <br />�1 BUSH PH ( ) <br /> CROSS STREET <br /> S <br /> CITY L-0STATE C-j�- ZIP_7aa <br /> St:�) LkD <br /> Census --------- BOS Dist Location Code City Cade ---------- <br /> IJL <br /> MAILING ADDRESS -41 APN <br /> i <br /> I <br /> CARE OF SIC CODE <br /> CITY .� J(J71.[�` _ STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> I <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME - HOME PHONE L ) <br /> MAILING ADDRESS BUSH PHONE ( ➢ <br /> CARE OF t } � <br /> i <br /> CITY/ STATE ZIP <br />