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SAN JOAGU(k TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL LTH DIVISION LYW D-�l 3 <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANCE OF BILLING DATE OF BILLING CHANCE / / DELETE <br /> J OWNER FILE <br /> 6 <br /> OWNER ID 2 / 7 CASE r BILLING PARTY Y / N <br /> Z <br /> OWNER NAME Sg?Qmr- Cc-LS DEjjet1. pmlata-t l_.,'�YY►PANy OWNER 94 PHONE ( ) CJZ;. - 3 <br /> OWNER-All"OWNER-All"IER-A (�K«�-. n&r- {`7�ct` <br /> Q l9�(LC F. j OWNER i@l4�ft PH ( )311-- L3 p l <br /> ADDRESS C , Q I✓ `��•' c'': <br /> CITY 1 7 1qN GA' STATE CA ZIP -} J c� <br /> p <br /> MAILING ADDRESS 0 6�� \ZSR YY~ aljTec� <br /> � . <br /> �• <br /> CARE OF } ^"- <br /> a <br /> CITY STATE ZIP <br /> c�O �- <br /> BUSINESS CODE NATURE OF 06NER BUSINESS r <br /> FACILITY FILE <br /> FACILITY ID M 7t�tf� BILLING PARTY Y / N <br /> /]'��(J 8 OF EMPLOYEES <br /> FACILITY NAME C•Q-G.L2�7(� TRUST LANDS? Y / N <br /> FACILITY ADDRESS —UI.C�(Y�V\ C-Cl-L�Q+�S � •NBME PX ( _) Z3- 3 1 Z <br /> CROSS STREET �C^�5E=1/V\AT2. A—,jGhV`�Le- ('+ SPH (�_)$Z 23 8 <br /> ,^ <br /> CITY '1 /\ptN�TGA STATE Js ZIP <br /> Census --------- SOS Dist location Code City Code ---------- <br /> Q Q1- 140- <br /> MAILING ADDRESS P, o \�O� L/� AP" f 3- 2-1(3 -S m( bS <br /> fl-t CNl Q <br /> BARE 9F. �/� ,�a Mf GOb Gree-h Sic CODE - <br /> CITY '1 V I -�• STATE �_ ZIP S 3� / <br /> GENERAL TYPE of BUSINESS at this FACILITY J;O Q1�Y12CS..V, <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAMEA ,t(tv✓1 K L fy- -AWE <br /> / <br /> PHONE ( Li799 <br /> HAILING ADDRESS 2,0o7 WFST 'o -Ck <br /> LC-v/1c BUSH PHONE ( ��'T ) 9 Stp- 2-(62q <br /> rr /ILn c,�l0A <br /> CITY STATE CAr ZIP ql, L1 <br />