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SAN JOAQUIN . .(TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL h .H DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) Re iS 5/14/93 <br /> NEW FACILITY V 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 J/j �� 3 a�, 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 # � 4qt BILLING PARTY `; Y / N <br /> OF EMPLOYEES <br /> FACILITY NAME � . .0) r 11 1r�EJXXI0�G TRUST LANDS? Y / N <br /> FACILITY ADDRESS i' LO I L.._ �CZI�"1 I\� HOME PH ( ) <br /> CROSS STREET BUSN PH ( ) <br /> CITY 'M STATE ZIP <br /> Census ----•---- SOS Dist Location Code City Code ----------- <br /> MAILING ADDRESS APN # <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 /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />