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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 5/14/43 <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 CASE # BILLING PARTY Y / 11 <br /> OWNER NAME OWNER HOME PHONE ( ) <br /> OWNER DSA OWNER WRK/BUS PH ( ) <br /> ADDRESS <br /> CITY STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> I <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ED # ! `, l� 41Lam <br /> �C) BILLING PARTY Y / N <br /> v�J 1 Ll 1 <br /> # OF EMPLOYEES <br /> FACILITY NAME TRUST LANDS? Y / N <br /> lj <br /> FACILITY ADDRESS U 1 v HOME PH <br /> CROSS STREET { 7 BUSN PH ( ) <br /> CITY STATE ZIP <br /> Census --------- 80S Dist Location Code City Code .......... <br /> MAILING ADDRESS APR # <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 <br /> CARE OF <br /> CITY .-STATE ZIP � \\ <br />