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De1 26 13 11:24a JP Petrolourn Service 9 142-4-8 1 W-­"� C <br />IVED <br />'* �.t * � " 2 <br />SAN' JOAMIN COUNTY ENVRONMENTAL HEALTH DEPART,"A5NTIL <br />SERVICE REQUEST <br />Typ-- ol Business or Property A M 90M <br />CIL! r(10# <br />01,10%1-7-P I OPERATOR <br />1sLe5 R., -fp <br />CHECK 13eu'ala ADDPESS <br />- <br />FACILITV NAM <br />ACCEI T-=[) EY: <br />SHE ADDRESS -ii <br />ASSIGPED TO: <br />13atc- S L-rVjc a CoMpleted (if alreally corn plotcd)' <br />i r-rif'LOYP_:r: <br />Fee A aunt: A',m c u nt Paid <br />I Payment Data <br />Faymcnt Tye <br />lnvoi t <br />mck24 Recialvied By: <br />HOME Or MAILNG ADDRESS <br />r <br />CITY <br />STA zip <br />PH IE 41rt7."Na <br />USr APP-ICAT1014 fi <br />Pi iom 12 <br />C 0 N T R A OCT 0 R SEAR' V I C R E Q U US -10 R <br />-i�ECIUE57`OR ri i.. f c,'47ce, if BILL -,N- Appgm$ <br />BUSINE�-Sg NAME <br />44m,,P- or MAwric; AD DRESS <br />zip <br />BILLING ACKNOWLEDGEMENT; I. tie urldersigned property C' bu5;nesE owns- ope.a�tar -.i authorbuod agent of sarnw, <br />ar,kw.m,edqe mat alt sL`ae a-iclJor projm Sped o^. hzLr1%-- C,=rges zssocig'=--c w.:h pro—'tit Cr <br />attivity-,-Xl be billed to mo or My but;1fiess as 7;d-arltified Cri 1hiS fOrr", <br />also certify that f havo pre,1jzx-ej this: applicalion andt,48e the WO: k "C. wn ra dorm :n az=,rcanre w"; ati S; Jo.;oui.,; <br />G;LN7e Ordipant-F, Crrd&s, Slantrar&�. ST.:t:-,51 and <br />APPLICANT'S 5IGNATURE, <br />P.qcpotT-! BUSINESS 0WNER 6PERATORf-firk4AGER <br />If APPLjrA, . I:Sror the 1-7K <br />-o _PART�. proof V, a hcfizazion 1r, 5;-017 15 :-UQUfred <br />AUTHORiZATION TO RELEASE- INFORMATION: ljl!ren -applicsnie, .1. :.76 ovmer'3, cperazo,- juroper'y I=.ated at "!7e -PbDve <br />site address. hereby authorl?e te re!aaSa of and; zw resu'!F" cemechnica, dazi B' <br />W In* SAN J0AZ:UN C-'OIWN7Y as sco;- as it aja;;r,cja ar he ;nmr, t.;ma ?L is 3'a".ided t-, me "6r <br />my representaVve. <br />-- - - - <br />TYPE OF SERVICER ED: <br />I <br />ACCEI T-=[) EY: <br />ASSIGPED TO: <br />13atc- S L-rVjc a CoMpleted (if alreally corn plotcd)' <br />i r-rif'LOYP_:r: <br />Fee A aunt: A',m c u nt Paid <br />I Payment Data <br />Faymcnt Tye <br />lnvoi t <br />mck24 Recialvied By: <br />EHI) 48.02-025 s� <br />0711VO& <br />