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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILa' RECORD :NFORMATION FORM EX 01 15 (OWNFAC) Revis 3/26/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / / INACTIVE <br /> Prior Owner <br /> UNDER CONSTRUCTION C4ANGE OF BILLING DATE OF BILLING CHANGE / / DELETE <br /> OWNER FILE <br /> OWNER ID CASE # BILLING PARTY Y / N <br /> OWNER NAME T OWNER PHONE ( 45) 244 zt <br /> OWNER DBA /�Il r�„rn 5> - OWNER 'IRK/HUS ?H <br /> OWNER ADDRESS 9M�JAWWlll/Lr �/' <br /> OWNER CITY lA /(S(M/Iw STATE ZIP 4,cz- <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID ��- � BILLING PARTY Y / NO <br /> # OF EMPLOYEES <br /> FACILITY NAME _ TRUST LANDS? Y / N <br /> FACILITY_' ADDRESS � � HOME PH ( ) <br /> CROSS STREET BUSN PH <br /> CITY / STATE l/, ZIP / <br /> Census --------- BOS Dist �I Location Code Q I C'_ty Code ----------- <br /> MAILING .ADDRESS `PN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACIILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS 3USN PHONE <br /> CARE OF <br />