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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) RMS 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 to CASE 0 BILLING PARTY T / N <br /> OWNER NAME A mu l cavi �czj,g j b¢ol-- OWNER HOME PHONE (G ) (� •b3� <br /> OWNER DBA }-� �, ` OWNER WRK/8US PH ( ) <br /> ADDRESS 400 t , 1 040 S QQ��1 4 IDDC <br /> CITY J�V(AL�Vh STATE \T ZIP' �'S 2q 0 <br /> MAILING ADDRESS ` -02 Co+ MoL.{K Skfee-t :Flovr 6"r U qS 2q© <br /> CARE OF REC VED <br /> CITY STATE ZIP APR 1 7 1995 <br /> ENVIRONMENTAL HEALTH <br /> BUSINESS CODE NATURE OF OWNER BUSINESS QCC)AAIT/CCD\!Il�CS <br /> FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / N <br /> 0 OF <br /> FACILITY NAME I+S 17 S+D&L� -Yl �Ca h TRUST LANDS?ES Y / N <br /> =AGILITY ADDRESS 2/L2 N ` Pk OO`QGW Skat I S�Tw-n, ` �/1� HOME PH ( ) <br /> '_ROSS STREET C�`Q V\V\e,1 J�`��� BUSH PH ( ) <br /> CITY STATE ZIP <br /> Census --------- SOS Dist Location Code City Code ----•------ <br /> HAILING ADDRESS APR <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> 1:•- _ _ �SINESS CSE 3USINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION 1 <br /> NAME VXJ 1C(MYY\ey&-` �1S�L N UI�CVT12Wr `f '_ HOME PHONE (�ur <br /> 0X00 <br /> I-7 a-7 Vow ka(Y kcLr, PSUt�e zoz)o -j(VlV1e- BUSH PHONE ( .4`{" J70D <br /> ((�� <br /> CA. q �7t4 <br /> CARE OF R1�0Ake Pf k MUD Pag, <br /> CITY -1''l j l"-e- STATE CA ZIP 9/2 <br />