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SAN JOAQUIN WY PUBLIC HEALTH SERVICES - ENVIRONMENTAL &H DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) Revis 8/26/93 <br /> NEL! 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 ID CASE # BILLING PARTY Y / N <br /> OWNER NAME OWNER HOME PHONE ( ) <br /> OWNER DBA OWNER WRK/BUS PH ( ) <br /> OWNER ADDRESS <br /> OWNER CITY 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 # BILLING PARTY Y / N <br /> # OF EMPLOYEES <br /> FACILITY NAME TRUST LANDS? Y / N <br /> FACILITY ADDRESS HOME PH ( ) <br /> CROSS STREET BUSH PH ( ) <br /> CITY STATE ZIP <br /> Census --------- BOS Dist Location Code 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 INFORMATION <br /> NAME HONE PHONE ( ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />