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SAN JOAQUIN COUI IUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL )(VISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 8/26/93 <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 L; LJ�,,L/-z" CASE # BILLING PARTY <br /> oy <br /> / N <br /> JA <br /> OWNER NAME g ,LOWNER NOW PHONE t ) <br /> OWNER DBA 12Q& Z14 4 C4 OWNER WRK/BUS PH ( ) <br /> OWNER ADDRESS <br /> OWNER CITY / V kIyG STATE �� ZIP <br /> MAILING ADDRESS /16)0 LVOL � <br /> CARE OF �� ClCITY A/l e,,ece STATE � [! <br /> • ZIP 6)J0-5-- <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # r� BILLING PARTY Y / <br /> Zt�g, <br /> / OF EMPLOYEES <br /> FACILITY NAME , /I z1-5- TRUST LANDS? Y / N <br /> FACILITY ADDRESS �i` � / [ . 42e. HOME PH ( ) <br /> CROSS STREET USH BPH <br /> ( <br /> CITY ,, `�55 `='� STATE _(� ZIP G j/ <br /> Census --------- SOS Dist Location Code f City Code '--------- <br /> MAILING ADDRESS (o d �/'I //`tG�/1 L �f,�i� APH # <br /> CARE OF SIC CODE <br /> �?�� <br /> CITY L�/'`U< 7d12 STATE ��< ZIP 7 07 <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BIIL�LING INFORMATION <br /> NAME OAA - HOME PHONE t ) <br /> MAILING ADDRESS 0 / BONE <br /> USN PHM ( ) <br /> CARE OF � ' "'4 <br /> CITY 4AI��O� STATE ZIP <br />