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• , , SAN JCAOUINOTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL ON DIVISION <br /> NASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) Revis 5/14/93 <br /> NEW FACILITY ! CHANGE OF OWNER DATE OF OWNER CHANGE / /_ INACTIVE <br /> Prior Omer <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / /_ DELETE <br /> OWNER FILE <br /> OWNER ID ✓CO l� CASE 4 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 I <br /> FACILITY ID /JS/� � r /? BILLING PARTY i�l Y / N <br /> / SAN/nom, R OF EMPLOYEES <br /> FACILITY NAME TRUST LANDS? Y / N <br /> I�G] <br /> FACILITY ADDRESS / ' / �O �• WC-� HOME PH ( ) <br /> BUSH PH ( ) <br /> CROSS STREET <br /> CITY � � STATE ���� ZIP <br /> Census •-------- BOB Dist <br /> Location Code City Code - <br /> MAILING ADDRESS APN X <br /> SIC CODE <br /> CARE OF <br /> CITY L�C -Q— >� STATE ��" — ZIP •7.73 <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CCDE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY 9ILLING INFORMATION <br /> HOME PHONE ( ) <br /> NAME <br /> BUSN PHONE ( ) <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br />