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SAN JOAQUIN COUIJTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAKH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revfs 5/1 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / / <br /> INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE �� DELETE <br /> OWNER FILE <br /> OWNER IO CASE 0 BILLING PARTY Y <br /> OWNER NAME yMfLC CQV\ �Q,jn4S �Q� OWNER HOME PHONE (2-L •b3�.5 <br /> OWNER DBA 3 OWNER WRK/BUS PH ( ) <br /> ADDRESS -COO S 9CLi \ J�(Q('i � iDD` <br /> u ( /v 0 <br /> CITY G n STATE � zip I✓c 2q o <br /> MAILING ADDRESS `C �� `"aiy, Sk-fC/e-t �RoDr I S.\-oi -", <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID 9 BILLING PARTY Y / <br /> IM OF EMPLOYEES <br /> FACILITY NAME I }S�3 � v'—1 bY` ��aYUC/� TRUST LANDS7 Y / N <br /> ;ACILITT ADDRESS 22Skyet S1 V }l. HOME PH ( ) <br /> :ROSS STREET v' `a I^�� S �\ BUSH PH ( ) <br /> CITY STATE ZIP <br /> Census ---•••••• HOS Dist Location Code Clty Code •---------- <br /> 4AIL1NG ADDRESS APR X <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> BUSINESS :wE 3USINESS TYPE (UST) <br /> 1 I I <br /> THIRD PARTY BILLING INFORMATION ` 1 <br /> NAME (2 J l ('1�Y)'�(Z{'�TG\ tS k vlaievll ew} I ' HOME PHONE C_I I�I ) -�DO <br /> BUSH PHONE .44C5 -770L <br /> CARE OF 1�.��Y�Ie �I vherD 114 Png <br /> CITY J ��� STATE GP ZIP 92114 J <br />