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SAN JOAQUIN CC PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA 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 /> OWNER ID CASE # BILLING PARTY Y / N <br /> OWNER NAME �J IA IV���A(1 OWNER HOME PHONE ( ) <br /> OWNER DBA OWNER WRK/BUS PH ( ) <br /> ADDRESS <br /> CITY STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> a FACILITY ID # FCLE --) r <br /> BILLING PARTY Y / N <br /> # OF EMPLOYEES <br /> FACILITY NAME fA(I(IA AA TRUST LANDS? Y / N <br /> FACILITY ADDRESS �O</rJZ 1 IYti1 �✓ 1� HOME PH ( ) <br /> CROSS STREET BUSN PH ( ) <br /> CITY L` d� '�W� STATE —Lt-- ZIP <br /> CensusSOS Dist Location Code City Code --------- <br /> MAILING ADDRESS APN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODEI BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME - INV HCME PHONE ( ) <br /> AL <br /> MAILING ADDRESS BUSN PHONE (�) II' <br /> CARE OF �' (��J) 'E�g.J�l� ✓ 4 <br /> CITY IA STATE ZIP -U VFIDINTI <br /> THIRD PARTY <br />