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ENVIRONMENTAL HEA:'H DIVISION <br /> SAN JOAQUIN CwNTY MASTERFILEBLIC HEALTH <br /> RECORD 114FORMA110H FORM <br /> EH 01 15 (OWUFAC) Revis 5/14/93 <br /> INACTIVE — <br /> — _ DATE OF OWNER CHANGE — <br /> NEW FACILITY �✓ CHANGE OF OWNER DELETE <br /> Prior Owner —/ / <br /> UNDER CONSTRUCTION <br /> CHANGE OF BILLING DATE OF BILLING CHANGE <br /> OWNER FILE <br /> 7 CASE # <br /> BILLING PARTY o / N <br /> OWNER ID <br /> Q. <br /> OWNER NAME l 0 r�.3 OWNER HOME PHONE <br /> OWNER DBAy � ' i n / OWNER WRK/BUS PH <br /> ADDRESS O r7O X 2y0 I <br /> CIA <br /> CITY �Ct-`v kC-00,-� STATE ` ZIP LJ <br /> MAILING ADDRESS) <br /> CARE OF <br /> CITY (�STATE \\ ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # F 3 BILLING PARTY Y / N <br /> r�✓c O ""` / f # OF EMPLOYES <br /> FACILITY NAME / f /� , D ° TRUST LANDS. Y / N <br /> FACILITY ADDRESS V lam{W HOME PH (�) _- <br /> CROSS STREET '` � � BUSN PH ( ) <br /> CITY STATE_ ZIP /S U <br /> Census ------ - BOS Dist Location Code City Code -------- - <br /> MAILING ADDRESS APN # CJ lO �Z,® <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 BUSN PHONE C ) <br /> CARE OF <br /> CITY STATE ZIP <br />