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i SAN JOAQUINOTY_ PUBLIC HEALTH SERVICES - ENVIRONMENTAL H H DIVISICH <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (CWHFAC) 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 1D CASE I! BILLING PARTY Y / <br /> OWNER NAME OWNER HCKE PHONE C } <br /> -712 <br /> OWNER DBA OWNER WRK/SUS PH C 07 �+ � <br /> ADDRESS tet% <br /> CITY _�1�1 T �� `�1t � STATE k-44%—. ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> STATE ZIP <br /> CITY <br /> � <br /> BUSINESS CODE NATURE OF OWNER BUSINESS "`&4 <br /> FACILITY FILE <br /> [FACILITY ID X fry"�► BILLING PARTY Y I ( N J <br /> r 1f OF EMPLOYEES <br /> FACILITY NAME C� TRUST LANDS? Y / N <br /> FACILITY ADDRESS uCJ HOME PH ( ) <br /> CROSS STREET BUSH PH ( ) <br /> CITY .. STATE `-'lit ZIP 95 <br /> Census SOS Dist Location Code O ( City Code - <br /> MAILING ADDRESS APR 0 <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 COST) <br /> THIRD PARTY BELLING INFORMATION <br /> NAME L i t Db L[1MLIWEYtswHOME PHONE { ) <br /> !4A I L i NG ADDRESS J IV�+ q- BUSH PHONE (� ) I✓Z.' gag <br /> � aD9I9�Z Z3� r <br /> CARE OF / f <br /> r 'v <br /> CITY STATE ZIP <br />