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SAN JOAQUIN fTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HF H DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (CWNFAp 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 _J /_ DELETE <br /> OWNER FILE �. . <br /> OWNER ID CASE # BILLING PARTY Y <br /> OWNER NAME OWNER HOME PHONE ( ) F <br /> OWNER DBA ^� �® OWNER WRK/BUS PH ( ) <br /> ADDRESSLJ7 <br /> CITY ( J! � C�Y(J9� Y� STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP ' <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # � Q BILLING PARTY Y / U <br /> I v <br /> # OF EMPLOYEES <br /> FACILITY NAME �l/(,f/X1'LN.-C,/ �V( I/h�I/YA 1 TRUST LANDS? Y / N <br /> FACILITY ADDRESS - ` v� W % 1-(�///l(�Q'(i1 HOME PH ( ) <br /> CROSS STREET ,. ,' /,,• / �y BUSH PH ( ) <br /> CITYSTATE ZIP <br /> Census - - - - -- - -- 80S Dist Location Code D I City Code -- • -- ------ <br /> MAILING ADDRESS APN # <br /> CARE OF SIC CODE <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 <br /> INFORMATION <br /> NAME l �illJ(/ L�LN� 1 L/��1�+/�/q",+,L,r�v/J NOME PHONE ( ) <br /> MAILING ADDRESS ll�Or !/ / /LL /YVPfK— .C_CJ BUSH PHONE <br /> CARE OF <br /> CITY STATE ZIP % LXD <br />