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SAN JOAQUIN CO Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE}Rav DIVISI <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (WNFAC) Revis 5/14/93 <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 f0 CASE # BILLING PARTY Y / N <br /> OWNER NAME _ 4 XPi d 1 5 ' "t Irg0 8 C k OWNER HOME PHONE C ) <br /> OWNER DBA OWNER WRK/BUS PH (o2/3 ) a 5-3 - 32(1-5- <br /> ADDRESS <br /> 1SADDRESS 333 Soclfin CTV-,�h,d4v2c.`,w--�) Sul f L-20 C7 <br /> CITY 4o /e S STATE CJ ZIP 400.7/ <br /> MAILING ADDRESS cSCAk1t2 CS Ct�dVZ <br /> CARE OF <br /> CITY STATE ZIP 11 <br /> BUSINESS CODE NATURE OF OWNER BUSINESS �✓t ah Gi'q' i�s4;+Lj+'OK <br /> FACILITY FILE <br /> FACILITY ID # / 71YI" BILLING PARTY T / N <br /> / 0 OF EMPLOYEES <br /> FACILITY NAME ���!5 ►'9 G h k TRUST LANDS? Y / N <br /> FACILITY ADDRESS 7` / �d�iG✓/�Sd HOME PH f ) <br /> CROSS STREET E r�s f ar K¢ f S r��¢+2 J BUSN PH ( ) <br /> CITY S�"d -�d STATE CA ZIP <br /> Census --------- 60S Dist Location Code City Code ----------- <br /> MAILING ADDRESS 5G-L..-e— cS q4d0-e- APN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CCCE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING INFORMATION�^1 <br /> NAME i/(/�IG��V1�1 f'TK'ti�Y1L��S HOME PHONE ( ) <br /> MAILING ADDRESS //5-20 5f-,4e. Stre-t BUSN PHONE ( 818 ).V V <br /> CARE Of f���r�� ���L►'adH Page IOA <br /> CITY STATE CA ZIP q/2�l <br />