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i r <br /> SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> �. MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 5/14/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE �J / INACTIVE <br /> Prior Owner - <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANCE /�_f DELETE <br /> OWNER FILE <br /> OWNER ID CASE # BILLING PARTY (Dy / N <br /> OWNER NAME CA/Lt.C{ vl a(L-1 Q �7S Y. OWNER HOME PHONE <br /> OWNER DBA Z5 c r° Qld COSY OWNER WRK/BUS PH (C�62) —� <br /> ADDRESS ! �S L '�"��iL T / li/ Y1/-,L!/�-{ —�— <br /> CITY STATEC/J ZIP JC r�Jf <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY STATE _ ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> q FACILITY FILE <br /> FACILITY ID # BILLING PARTY Y / N <br /> - p�am,' # OF EMPLOYEES <br /> FACILITY NAME ki fes_l_ l " S�(�C�!/1��aL( W� li TRUST LANDS? Y / N <br /> FACILITY ADDRESS ._ a C�� �S� L/ -� HOME PH ( } U3p- <br /> CROSS STREET W L� ( `L q ]�11 BUSH PH (cPo 7) <br /> _ CITY STATE li/���. ZIP �3 <br /> I <br /> Census --------- SOS Dist Location. Cade City Cade ---------- <br /> MAILING ADDRESS ��yL APN # j <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) i <br /> THIRD PARTY BILLING INFORMATION E <br /> NAME HOME PHONE ( ) <br /> MAILING ADDRESS BUSN PHONE ( ) <br /> i <br /> CARE OF Page IOA <br /> CITY STATE �,, ZIP <br />