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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 <br /> CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> DELETE <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE <br /> OWNER FILE <br /> CASE t! BILLING PARTY <br /> OWNER 1D <br /> OWNER NAME ��-�W�� i�� OWNER HOME PHONE ( ) <br /> OWNER WRK/BUS PH ( ) <br /> OWNER DBA <br /> ADDRESS <br /> CITY`' STATE CA ZIP <br /> MAILING ADDRESS <br /> CARE OF l tel/! CL/C c� / COLI G✓� i �z o9_9Y,-�37 f� <br /> CITY � cJC�CG�UII� STATE Z7-- ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> BILLING PARTYLl <br /> Iii; FACILITY ID # <br /> 0 OF EMPLOYEES <br /> TRUST LANDS? Y / N <br /> FACILITY NAME <br /> HOME PH ( ) <br /> FACILITY ADDRESS S <br /> BUSH PH ( ) <br /> CROSS STREET <br /> n ZIP <br /> CITY STATE <br /> Dist <br /> Location Code City Code "" <br /> Census --•---•-- BOS � 7 <br /> APN # <br /> MAILING ADDRESS <br /> SIC CODE <br /> CARE OF <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> 7 <br /> UST FAC STATUS CODE rI' <br /> BUSINESS CODE BUSINESS TYPE (UST) 1j <br /> THIRD PARTY BILLING INFORMATION <br /> ' HOME PHONE ( ) <br /> NAME <br /> BUSN PHONE ( ) <br /> MAILING ADDRESS <br /> CARE OF <br /> STATE ZIP <br />