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Y� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 8/2£/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / / <br /> INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION <br /> CHANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> if CASE # SICCING PARTY Y / N <br /> OWNER ID `lfJ� 7 <br /> OWNER NAME <br /> D r�G OWNER HOME PHONE <br /> OWNER WRK/BUS PH ( ) <br /> _ OWNER DBA <br /> OWNER ADDRESS <br /> OWNER CITY C /] STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF e J • a �Q ) <br /> CITY 4V7 S STATE. L_ ZIP v <br /> BUSINESS CODE NATURE CF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID # D , BILLING PARTY Y / N <br /> # OF EMPLOYEES <br /> FACILITY NAME ✓ , k v I� �_ TRUST LANDS7 Y / N <br /> FACILITY ADDRESS 1V D HOME PH <br /> CROSS STREET psij • V ' 'v BUSN PH <br /> CITY STATE ZIP <br /> Census7 BOS Dist Location Code City Code ----------- <br /> _J� <br /> MAILING ADDRESS APN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE Of BUSINESS at this FACILITY <br /> UST FAC STATUSCODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFFORMATIO14 <br /> NAME F— l — ' r <br /> HOME PHCNE <br /> MAILING ADDRESS jo iI ' ` I BUSN PHONE (O'rp/O <br /> CARE OF <br /> ✓! 4 o R �i4 Y �G L n 7�-S `�� C70 9`f O -�7'2 c c) <br />