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SAH JOAQUIN C( PUBLIC HEALTH SERVICES - ENVIRONMENTAL HW DIVISION 1S (ONNFAC) Revis 8/26/93 <br /> MASTERFILE RECORD INFORMATION FORM EA <br /> LNEWFACIL Y CHANGEOF OWNERDATE OF.ONNERCHANGEINACTIVE <br /> Prior Owner DELETE <br /> STRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE /,�� <br /> OWNER FILE .i <br /> =ASE BILLING PARTY N <br /> OWNER ID <br /> �`�`� r:OWNER HOME PHONE ( ) <br /> � ?( d <br /> OWNER NAME <br /> OWNER NRK/BUS PH <br /> OWNER DBA <br /> :a <br /> OWNER ADDRESS <br /> STATE ZIP I <br /> OWNER CITY <br /> MAILING ADDRESS <br /> CARE OF <br />! <br /> CITY STATE ZIP <br /> 3 _ <br /> BUSINESS CODE NATURE OF OWNER BUSINESS .I <br /> FACILITY FILE <br /> FACILITY ID' # BILLING PARTY Y / N <br /> LOYEES <br /> Y C7Z4 MP <br /> TRUSTE LANDS? Y <br /> FACILITY NAME T <br /> FACILITY ADDRESS _ C�_ HA—m�--6 le-� HOME PH ( ) <br /> CROSS STREET `/� �-�` BUSN PH ( ). <br /> CITY ✓1 (� STATE ZIP <br /> i <br /> Census ------- <br /> -- sos Dise 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 (USF) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME NOME PHONE { ) <br /> MAILING ADDRESS BUSH PHONE <br /> CARE OF <br /> CITY STATE ZIP <br />