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_ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECCRD INFORMATION FORM EH O1 IS (OWNFAC) Revis 9/25i93 <br /> NEW FACILITY <br /> CHANGE OF OWNER DATE OF OWNER CHANGE / /_ INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION <br /> CHANGE OF BILLING DATE OF BILLING CHANGE / /_ DELETE <br /> OWNER FILE <br /> CASE # BILLING PARTY Y / N <br /> OWNER ID O 2 7 7.3 <br /> OWNER NAME <br /> OWNER HOME PHONE <br /> ( 1 <br /> OWNER WRK/HUS PH ( 1 <br /> OWNER DBA <br /> OWNER ADDRESS <br /> 1�,� o Lo ��sW VGSS (tea r E e 5b� <br /> r (Yl� © qy 9453,20OWNER CITY � STATE �4 � ZIP <br /> MAILING ADDRESS <br /> CARE DF <br /> G (an1 rf <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> PACT_:.ITY FILE <br /> FACILITY ID # �� 3�6 <br /> 3 BILLING PARTY v N <br /> �/ # OF EMPLOYEES <br /> I �A V 1 �� � � U TRUST LANDS? Y / N <br /> FACILITY NAME f " _�< ; <br /> R6�–PH (�i`�_ ) - <br /> FACILITY ADDRESS 1 V ����C, <br /> CROSS STREET �� ( �f- BURN PH (LU I 1j- 374— <br /> CITY qv <br /> STATE CA- ZIP <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 /> HOME PHONE ( ) <br /> NAME <br /> BUSN PHONE <br /> ;AILING ADDRESS ( ) <br /> CARE OF – <br />