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5 <br /> SAN d0A0UIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORIMATION FORM EH 01 15 {OWNFAC) Renis 8,16/93 <br /> NEW FACILITY _ CHANGE OF OWNER DATE OF "ER CHANGE / f INACTIVE <br /> Prior Omer _ <br /> UNDER CONSTRUCTION _ CHANGE OF BILLING DATE OF BILLING CHANGE DELETE <br /> OWNER FILE <br /> OWNER ID CASE it <br /> SICCING PARTY Y- <br /> OWNER NAME OWNER HOME. PHONE'-i ) , <br /> OWNER DBA OWNER WRIV9US'PH ( <br /> OWNER ADDRESS <br /> "" �- Y� ZIP V <br /> OWNER, CIT7 STATE Y Yz <br /> MAILING ADDRESS <br /> y. 3Sa4 <br /> CARE OFx < <br /> CITY STATE 2IP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FIDE <br /> FACILITY ID # BILLING PART?r: ,Y 7 `. N-`'-. <br /> # OF EMPLOYEES it <br /> FACILITY NAME r TRUST LANDS? .'" Y /.; N <br /> FACILITY ADDRESS V1HOME PH ( ) . <br /> CROSS STREET BUSK PH "C ?: <br /> c <br /> CITY STATE L ZIP <br /> Census - ----- BOS Dist Locati Code City Coote -- - <br /> NAILING ADDRESS APH'# L f <br /> Q� <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at thi's FACILITY <br /> -T-- <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) , <br /> THIRD PARTY BILLING TNFORMATION <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS BUSH PHONE ( ) <br /> CARE OF <br /> CITY STATE Zip <br /> v: <br />