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1 <br /> SAN JOAQUIN VTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL IH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EN 01 15 (OWNFAC) 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 ID 5 CASE # BILLING PARTY Y / N <br /> OWNER NAME OWNER HOME PHONE ( ) <br /> OWNER DBA OWNER WRK/BUS PH ( t5A) )Z Z3 5T <br /> ADDRESS <br /> CITY STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITYR."9'' STATE/r Z1P <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # - /�� BILLING PARTY Y / N <br /> OF EMPLOYEES <br /> FACILITY NAME <br /> ttu C,rg-(. �i"'�_�� � ( �T•,.�t � ,`,e," TRUST LANDS? <br /> -- <br /> FACILITY ADDRESS a f t' 'tom- " ' 4 HOME PH ( ) <br /> r <br /> CROSS STREET L�.i'I -' ft.... f BUSH PH ( ) <br /> CITY s- 5 STATE CA ZIP 2 <br /> 0- <br /> Census --------- 80S Dist location Code g City Code ------...- <br /> MAILING ADDRESS <br /> APM <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 />