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- SAN JOAQUIN TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL N 'H 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 CHANCE OF BILLING DATE OF BILLING CHANGE / / DELETE <br />OWNER FILE <br />OWNER ID CASE # BILLING PARTY Y / N <br />OWNER NAME OWNER HOME PHONE <br />OWNER DBA ; �i! _ OWNER WRK/BUS PH ( ) <br />ADDRESS �' U 6 <br />CITY f' STATE ZIP <br />MAILING ADDRESS <br />CARE OF <br />CITY STATE ZIP <br />BUSINESS CODE NATURE OF OWNER BUSINESS <br />FACILITY FILE <br />FACILITY ID k 4,5 7 0 BILLING PARTY Y / N <br />MAILING ADDRESS <br />CARE OF <br />CITY <br />-c en-,u <br />ensus--------- SOS Dist Location Code I I <br />City Code <br />STATE ZIP <br />GENERAL TYPE of BUSINESS at this FACILITY <br />APN # <br />SIC CODE <br />UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE CUST) <br />THIRD PARTY 3ILLING INFORMATION <br />NAME <br />MAILING ADDRESS <br />CARE OF <br />CITY <br />STATE ZIP <br />HCME PHONE ( ) <br />BUSN PHONE ( ) <br /># OF EMPLOYEES <br />FACILITY NAME <br />TRUST LANDS? Y / N <br />�J <br />cab <br />'L f' <br />FACILITY ADDRESS <br />d�`Y�G <br />6%�J� HOME PH ( ) <br />—"" <br />{' t <br />PH <br />CROSS STREET <br />BUSH ( ) <br />7& <br />CITY I <br />' f <br />STATE–%C ZIP <br />MAILING ADDRESS <br />CARE OF <br />CITY <br />-c en-,u <br />ensus--------- SOS Dist Location Code I I <br />City Code <br />STATE ZIP <br />GENERAL TYPE of BUSINESS at this FACILITY <br />APN # <br />SIC CODE <br />UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE CUST) <br />THIRD PARTY 3ILLING INFORMATION <br />NAME <br />MAILING ADDRESS <br />CARE OF <br />CITY <br />STATE ZIP <br />HCME PHONE ( ) <br />BUSN PHONE ( ) <br />