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SAN JOAQUIN�' UNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL\*,ALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 8/26/93 <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 1D �Cj� CASE # BILLING PARTY Y N <br /> OWNER NAME ��f yC ��' /'/(��%/ CC-� OWNER NOME PHONE <br /> �/ C= /� l OWNER WRK/BUS PH ( <br /> OWNER DBA /' � / `7 Z f[� <br /> OWNER ADDRESS <br /> OWNER CITY ?C 'C11 7 c�/Y STATE ZIPt- <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID #7 <br /> 0 3 BILLING PARTY Y N <br /> n/� # OF EMPLOYEES <br /> FACILITY NAME���� —�(`� IC '(�LI�� N[`Z 1 • 1LL-VV/,]K _. TRUST LANDS? Y / N <br /> FACILITY ADDRESS '-�e'1 �i� 1 /�1/�I - HOME PH <br /> CROSS STREET L 12d\1LI !4ycc . BUSH PH <br /> CITY� A-71,/K/ STATE<L"f ZIP <br /> Census --------- SOS Dist Location Code City Code ----------- <br /> MAILING ADDRESS EY �� �L((C�• 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 /> THIRD PARTY BILLING INFORMATION <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> CARE OF I <br /> CITY STATE ZIP <br />