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SAN JOAQUIN ...�.TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL Ham..-,rH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) 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 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 /> FACILITY ID k BILLING PARTY Y .Y N <br /> -(7 / �, 1 # OF EMPLOYEES <br /> FACILITY NAME 3iG'Ty-7�! i�,/�fA�PfC�-71Y/2``Y TRUST LANDS? Y / N <br /> FACILITY ADDRESS 3z��Z AV(T! ) l Zarl�4h� �Y-\11`L'�i HOME PH ( ) <br /> rG.ril CROSS STREET Ho BUSN PH ( ) <br /> bhrnor _ <br /> A4-,f5 CITY STATE ( ! ZIP C� L ?- <br /> e;rvb6C4 <br /> 96`6-ov) <br /> Census •-------- BOB Dist Loca[i on Ccde City Code ---•---•--- <br /> MAILING ADDRESS APN # <br /> CARE OF SIC CODE <br /> CITY S"ATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS <br /> CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HCME PHONE ( ) <br /> NAILING ADDRESS BUSH PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />