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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • ENVIRONMENTAL HEALTH DIVISION <br /> 1 a • MASTERFILE RECORD INFORMATION FORM EH O1 15 (OWNFAC) Revis 5/14/93 <br /> t NEN 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 � ��Z I� CASE # <br /> BILLING PARTY Y / <br />' OWNER NAME I��/�7- L7J .�y71�`�J•j,� OWNER HOME PHONE ( ) <br /> C O <br /> OWNER WRK/BUS PH <br /> ADDRESS / "7� G✓✓f /NfT�/1/ <br /> 1a6b 3z <br /> CITY � O /r N STATE ZIP �y�/ S`2-01 �uv.D <br /> MAILING ADDRESS C �f �✓/•�.,. - -. �D1 - <br /> CARE OF �������7✓s � � �- <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS �Cl ,Qfii pJ`�Qi !fi <br /> FACILITY FILE <br /> a FACILITY ID 9 /�/jf �`7��Z BILLING PARTY / N� <br /> # OF EMPLOYEES fff <br /> FACILITY NAME C'4R61166 All fyL--ff��' E ` TRUST LANDS? Y / <br /> FACILITY ADDRESS x`00017- eye:, -155ir `<217W lz©,4"D HOME'PH ( ) <br /> GBGS6-3TftEET d/fiCK�� �"f 4-r / BUSH PH ( -z"09,) O9� <br /> CITY �� ��� STATE /¢- ZIPS Z� <br /> Census --------- 80S DistF--1 Location Code City Code <br /> MAILING ADDRESS <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODET- BUSINESS CODE BUSINESS TYPE CUST) <br /> 4 <br /> THIRD PARTY BILLING INFORMATION/ <br /> f NAME /Y7 HOME PHONE ( ) <br /> MAILING ADDRESS BUSH PHONE C ) <br /> CARE OF e t <br /> CITY 9TATE'74- + ZIP <br />