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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM 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 C (L <br /> OWNER ID ('DCASE # BILLING PARTY Y / 8 ' <br /> ----= <br /> OWNER NAME am� G o f P 5o u OWNER HOME PHONE <br /> ✓ � h 0 <br /> / <br /> OWNER DBA OWNER WRK/BUS PH (✓ ) <br /> ✓ <br /> ADDRESS O 6 k SL <br /> CITY .� a T STATE ZIP Y 7� <br /> /D�U Jt-- <br /> MAILING ADDRESS✓ Him <br /> CARE OF <br /> CITY ✓ STATE J ZIP Y <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE Ln•.�/J_ <br /> FACILITY ID # /7�� BILLING PARTY Y <br /> / tv r - # OF EMPLOYEES <br /> FACILITY NAME J TRUST LANDS? Y / N <br /> / ooq HOME PH <br /> FACILITY ADDRESS ✓�yE Co�1J�-✓ C]r �g6,aN V- `,u M1,NPrS T/ � ) <br /> CROSS STREET <br /> '©go�o J _ BUSN PH <br /> CITY vl ��siU[ STATE -4• ZIP <br /> T- I <br /> Census <br /> BOS Dist Location Code City Code <br /> APN # <br /> MAILING ADDRESS <br /> SIC CODE <br /> CARE OF <br /> CITY STATE 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 l"I( / Q P �OC� 2� SoNPa �� P/ D 101Nt°(Jr HOME PHONE ( ) <br /> MAILING ADDRESS �0 IDr�� 57 BUSN PHONE <br /> CARE OF Cfr 7 <br /> CITY STATE ZIP [ 7 7h <br />