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1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> HASTERFILE RECORD INFORMATION FORM EH 01 15 (CWHFAC) 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 Q CASE a BILLING PARTY Y / N <br /> OWNER NAME (�P I iDlt} 'l a= 2WrER HOME PHONE ( ) <br /> OWNER DBA OWNER WRK/BUS PH ( 1 ).4tdS- <br /> ADDRESS 1� I + N Pr, y,f (,rVic6L -_ <br /> CITYSTATE �� ZIP <br /> MAILING ADDRESS 5/14 <br /> MCARE OF 'Don A1 y W lYlDer <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID 9 00 73 Y7 BILLING PARTY Y / N <br /> l I OF EMPLOYEES <br /> FACILITY NAME r `Lr1 TRUST LANDS? Y / N <br /> F <br /> FACILITY ADDRESS J E HOME PH ( ) <br /> CROSS STREET { I }4- �ll-.l3 rE,lIGi BUSH PH ( ) <br /> CITY STATE ZIP <br /> Census ----- <br /> SOS Dist Location Code City Code -------- <br /> MAILING ADDRESS EVA APN 9 <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> r THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE C ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> -CARE OF <br /> CITY STATE ZIP <br />