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SAN JOAOUINQNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL*TH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 8/26/93 <br /> NEW FACILITY 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 ��� CASE # BILLING PARTY Y / N <br /> OWNER NAME D OWNER HOME PHONE <br /> OWNER DBA (C, /C 1 I OWNER WRK/BUS PH (d l� ) �a —7 <br /> OWNER ADDRESS <br /> OWNER CITY W� / STATE n4 ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / N <br /> # OF EMPLOYEES <br /> FACILITY NAME TRUST��I TRUST LANDS? Y / N <br /> FACILITY ADDRESS ( ��I�� HOME PH ( ) <br /> CROSS STREET / G1 I BUSH PH ( ) <br /> CITY L / STATE °' ZIP 3 C <br /> �� <br /> Census --------- 60S Dist Location Codl:E7— I <br /> City Code <br /> MAILING ADDRESS 1 �'`' 'iL-� '` CUv.`�y ��� APH # <br /> IUv��C <br /> CARE OF l J l`Tut S lS� A, SSG _ SIC CODE <br /> 7�YJs�o- S <br /> Ys7CITY, t✓I� ;c v�� STATE CA ZIP <br /> GENERAL P of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE ` 1� t Y`� BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE <br /> MAILING ADDRESS (O� �`/ � l 2-00 BUSN PHONE G <br /> CARE OF <br /> CITY _iiLIU/G� \�— STATE �/ ' ZIP �D6 <br />