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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTfRFILE RECORD INFORMATION FORM EN 01 15 (OWNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANCE Of OWNER DATE Of OWNER CHANGE / / INACTIVE <br /> Prior Ourwr <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE Of BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> OWNER 10 CASE 0 BILLING PARTY T / <br /> OWNER NAME�_ /"I /"'NC„eS� OWNER HOME PHOHE ( ) <br /> OWNER DBA OWNER WRK/BUS PH ) . <br /> ADDRESS <br /> CITY,>c ! / -7 STATE ZIP <br /> HAILING ADDRESS )C ; <br /> CARE OF X <br /> CITY X STATE ZIP <br /> I <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID N BILLING PARTY Y / <br /> / � 0 OF EMPLOYEES <br /> FACILITY NAME �^ �'4`�- -� _ _ -- -- -- - ------ - TRUST LAWS? Y / m <br /> FACILITY ADDRESS ?C 1��� N' tl�G�/ Y1� HOME PH { ) <br /> CROSS STREET BUSH PH ( ) <br /> CITY STATE?O ZIP X <br /> Census --------- BOS 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 SUSINESS CODE BUSINESS TYPE (UST) <br /> r <br /> THIRD PARTY BILLING INFORMATION <br /> NAME:-j4AE i l -cY_--�" ""�u7� i�-�� A PHONE (_c �l) 6q - <br /> MAILING ADDRESS I 4 S, ESTERO `---Z i L RX) BUSN PHONE ( O 1 ) Oy <br /> CARE OF LQ Q 1e T� %� L-c-) lc•_ Es Q y Page 10A <br /> CITY STATE ( ZIP <br />