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I <br /> - � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> i <br /> �/ M74STERFIL$ RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 8/26/93 <br /> NEW FACILITY /t CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE DELETE <br /> I ( OWNER FILE <br /> OWNER ID I CASE # BILLING PARTY Y / N <br /> I I " <br /> OWNER NAME NSW +tQ �a.F}� SlX <br /> OWNER HOME PHONE { Q 1 <br /> OWNER DBA N/Ar OWNER WRK/Bus Px <br /> - <br /> OWNER ADDRESS �5l0 � 11+�f �,r��Q 5.,, �` <br /> k <br /> OWNER CITY Stb�k �'� _ 452�� E EIV <br /> I STATE �� ZIP <br /> MAILING ADDRESS APR O 51996 <br /> CARE of '"NOWENTAL HEALTH, <br /> PERMIT/ SERVICES <br /> CITY STATE ZIP <br /> M y <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> i .FACILITY FILE <br /> I <br /> FACILITY ID # BILLING PARTY Y / Q <br /> # OF EMPLOYEES <br /> y FACILITY NAME '�pp (7 l TRUST LANDS? Y / N <br /> 4 <br /> FACILITY ADDRESS ���d 1V c,,r t, T✓dt C �Y���J4/'Q + HOME PH ( j <br /> CROSS STREET Co��7 V4� <br /> BUSN PH [ ) <br /> CITY T,�a< STATE CIS ZIP <br /> f <br /> 9 <br /> Census --------- BOS Dist Location Code City Coda <br /> 1 <br /> MAILING ADDRESS 5A•V' APN # <br /> s <br /> C <br /> A <br /> rr CARE OF <br /> SIC CODE <br /> 1 <br /> CITY STATE ZIP , <br /> w <br /> GENERAL TYPE of BUSINESS at this FACILITY IIZQ� �rMw�h..1� I? I <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE {UST) <br /> THIRD PARTY BILLING INFORMATION 'RA <br /> NAME f" `f. W ;1k 1 Q V.._ <br /> ` •E �J Q1 ��A. 1l` HOME PHONE ( } <br /> MAILING ADDRESS G33 VW�,� T�r (P <br /> � g .� M-3 $USN PHONE r Z13 <br /> CARE OF <br /> CITY 5 STATE �� ZIP <br />