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SAN JOAQUIN 1TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL I N DIVISION <br /> NASTERFILE RECORD INFORMATION FORM �.r EH 01 15 (OWNFAC) Revis 5/14/93 <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 u OWNER HOW PHONE t ) <br /> OWNER DBA LLLIL.— St Z _ OWNER WRK/BUS PH ( ) <br /> ADDRESS <br /> CITY � STATE k—V ZIP `'1—Til?t Z <br /> MAILING ADDRESS <br /> CARE OF T <br /> CITY id STATE 0,0-- ZIP 14i-2— <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> ?I FACILITY Ib # 1 4; K fljCJtP BILLING PARTY f YJ t N <br /> # OF EMPLOYEES -' <br /> FACILITY NAME - TRUST LANDS? Y / N <br /> FACILITY ADDRESS n O HOME PH < ) <br /> CROSS STREET // BUSH PH t ) <br /> CITY STATE `Cr+ ZIP 1� <br /> Census --•••••-• SOS Dist Location Code City Code •--•••-• <br /> MAILING ADDRESS _PO i t1a LJuC —L�� APN # <br /> CARE OF 4''- SIC CODE <br /> CITY _ I�IJllllli�_Q STATE ,A, ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> USI FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HCME PHONE t ) <br /> MAILING ADDRESS BUSH PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />