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SAN JOAQUIN Ccs Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL'H DIVISION <br /> 14. MASTERFILE RECORD INFORMATION FORM EN 01 15 (CWNFAC) 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 /_,�.f DELETE <br /> OWNER FILE ; <br /> OWNER iD �D CA5E # BILLING PARTY / N <br /> OWNER NAME �/ � OWNER HOME PHONE ( } <br /> OWNER DBA. - `' _ OWNER S PH As <br /> ... ADDRESS <br /> CITY STATE 00-- ZIP � b <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> i <br /> j FACILITY ID # BILLING PARTY Y / N <br /> # OF EMPLOYEES <br /> FACILITY NAME �' - TRUST LANDS? Y / N <br /> FACILITY ADDRESS t "'�', ' "` NOME PH <br /> �1L <br /> CROSS STREET ? BUSH PN C ) <br /> y C.-V a P T Y� <br /> `• CITY SPATE ZI' <br /> Census --------- EMS Dist Location Code City Code ---------- <br /> MAILING ADDRESS i APN $ <br /> f — <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 C ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />