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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 8/26/43 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE INACTIVE <br /> G <br />� Prior Owner <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> --FOiMER ID CASE # BILLING PARTY Y / N <br /> OWNER NAME / OWNER HOME PHONE <br /> OWNER DBA r OWNER WRK/BUS PH <br /> { { ) <br /> OWNER ADDRESS �V <br /> IN U-4 <br /> OWNER CITY STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ./ ZIP 7�u <br /> l <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> fACiLITY FILE <br /> FACILITY ID # ��/„Q� <br /> �wv BILLING PARTY Y / ON <br /> # OF EMPLOYEES <br /> i <br /> FACILITY NAME TRUST LANDS? Y / N <br /> FACILITY ADDRESS HOME PH ( ) <br /> CROSS STREET BUSN PH <br /> CITY STATE ZIP <br /> 7 Census --- SOS Dist Location Code cit Code1--- I <br /> MAILING ADDRESS APN # <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 /> i THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS /UX �! C% _ SUSN PHONE <br /> CARE OF <br /> CITY _ (rr� _ __ STATE ul ZIP r(� <br /> 1 <br />