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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE.LTH 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 / / DELETE <br /> OWNER FILE <br /> OUNER ID `� CASE # BILLING PARTY Y? / N <br /> i <br /> OWNER NAME ��-'✓'W�� OWNER HOME PHONE <br /> OWNER DBA OWNER WRK/BUS PH ( ) <br /> ADDRESS <br /> CITYd STATE _ ZIP <br /> MAILING ADDRESS <br /> CARE OF `C Ole-- <br /> CITY �l� �L"� STATE =Z_ ZIP 2-0 / <br /> BUSINESS CODE <br /> NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> ................................. <br /> FFCIL771 # C� BILLING PARTY Y / �N <br /> # OF EMPLOYEES <br /> TRUST LANDS? Y / N <br /> FACILITY NAME <br /> HOME PH ( ) <br /> FACILITY ADDRESS <br /> CROSS STREET ln `'� Q� /� f�� BUSH PH ( ) <br /> CITY ( ""` STATE ZIP <br /> I i ---------Census <br /> SOS Dist Location Code City Code -- <br /> MAILING ADDRESS APN <br /> SIC CODE <br /> CARE OF <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE I BUSINESS CODE tom' 7 BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> ( ) <br /> MAILING ADDRESS BUSN PHONE <br /> CARE OF <br /> CITY STATE ZIP <br />