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• � �WoiG6 boa-(O�� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEACIN DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revi• 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION CHANCE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> OWNER ID CASE # BILLING PARTY <br /> OWNER NAME Si- <br /> OWNER NOME PHONE (Z_`1 ) 7"S �- Z 1 <br /> OWNER DBA _ <�r-c��c— _ ����t OWNER NRK/BUS PH f7Z�9 4 Z 14- <br /> ADDRESS �c <br /> 4-ADDRESS �c 644- /-J. EC Flii.1.4L pp- - <br /> CITY <br /> P -CITY c--rr� L,L-r-c�._� STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF x _ <br /> CITY - - STATE ZIP 9 rte' -'Iiv <br /> BUSINESS CODE NATURE OF OWNER BUSINESS aH Wmmm. <br /> FACILITY FILE <br /> FACILITY ID # QS� �� BILLING PARTY Y / H <br /> # OF EMPLOYEES <br /> FACILITY NAME /A'L+ ✓�,=,--� iA J ^.4IS �1 =n- 'c�z✓ )� ��-- TRUST LANDS? Y / N <br /> FACILITY ADDRESS -1t-� / HOME PH ( ) <br /> CROSS STREET /4\6 BUSH PH ( ) <br /> CITY -i C�-�L7v✓ STATE S.z�, ZIP SIJ Zf7� <br /> Census ----••--- BOS Dist Location Code City Code ----------- <br /> MAILING ADDRESS APN # 1 (/, 3 - Cil.>C> " C, <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 M-s6c" ' HOME PHONE ( ) <br /> �1 t <br /> MAILING ADDRESS Z Z IJ ' 7 '`"" Sw'� L� t BUSN PHONE 7�, j <br /> CARE OF <br /> Page 10,9 <br /> CITY ��J ' <br /> STATE « ZIP �7 � L G-p <br />