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SAN JOAQUIN A PUBLIC HEALTH SERVICES - ENVIRONMENTAL HDIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF WNER DATE OF OWNER CHANGE / /_ INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE <br /> OWNER FILE <br /> OWNER ID CASE # BILLING PARTY Y / N <br /> OWNER NAME MA,etey coo-/AIJG mi)6C CONMAl y OWNER HOME PHONE ( ;Z07 ) • 3yS <br /> OWNER DBA 5AMC' RS OWNER WRK/BUS PH ( ) <br /> ADDRESS /SO -/ si.t/CL4/2 4116- • �1 n <br /> CITY S??TOGIGTON/ STATE CT ZIP _ 5-20J <br /> �� <br /> MAILING ADDRESS JvOV Fox K1 DCtE D� <br /> CARE OF PAVE / <br /> CITY MISS/ /L/ STATE° '�S ZIP <br /> BUSINESS CODE NATURE OF WNER BUSINESS <br /> 70UlrA FH6oe/C4T/0N <br /> FACILITY FILE <br /> r� FACILITY 10 k BILLING PARTY Y / N <br /> # OF EMPLOYEES <br /> FACILITY NAME <br /> /tgAR.JEy COOT;/A)(4 7-6VV4 CoMPA/vy TRUST LANDS? Y / N <br /> Al. � <br /> FACILITY ADDRESS 155-0 ASINC64/K• A HOME PH ( ) <br /> CROSS STREET BUSH PH ( 'LD <br /> CITY / �'C'K 74A) STATE eA- ZIP9S�ds <br /> Censu •• <br /> s •• 805 Dist Location Code City Code ---- <br /> MAILING ADDRESS -���V /"G.l'IeI�E D4• APN # <br /> CARE OF BATES SIC CODE <br /> CITY MISS/OX/ STATE6*Z 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 BUSH PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />