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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) 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 10i CASE # BILLING PARTY Y / N <br /> i�'l_"1 ,,,, <br /> OWNER NAME �/l/I u �'n ,�//���1'�&Ad-d Q RPhCyl <br /> e" gic— - SER HOME PHONE ( ) <br /> OWNER DBA / OWNER WRK/BUS PH (� � <br /> / A <br /> _) - �DD <br /> ADDRESS �I t 1 A0 '/ <br /> CITY DDA, �lt STATE ZIP �)L�Y <br /> RAILING ADORESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> fACIL1TY ID # j 'J BILLING PARTY Y / <br /> # OF EMPLOYEES <br /> FACILITY NAME C TRUST LANDS? Y / N <br /> FACILITY ADDRESS n d�•� HOME PH ( ) <br /> CROSS STREETn l,y"^T_y.t`rX �y BUSH PH ( ) <br /> CITY �J\M UDN STATE ZIP y 7 103 <br /> Census •••----•• SOS Dist Q` Location Cade Q ` City Code ---^•^-- <br /> MAILING ADDRESS APH # <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 HOME PHONE ( ) <br /> MAILING ADDRESS BUSH PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />