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I1-CfD <br /> SAN JOAQUIN,.OUNTY ENVIRONMENTAL HEALTH Jis PARTMENT <br /> SERVICE REQUEST <br /> • Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ASOliv6 �6/ Sr/6 1 2� S�Oo y 35�� <br /> OWNER/OPERATOR A <br /> / <br /> SAZEIN FUE/ Acelr //�/ CHECKBILLINGADDRESS� <br /> FACILITY NAME /� 1 /J '/ p <br /> SITE ADDRESS Z��O !IO//`CyUN7•¢yC/ltd 941p OGF��.t1 lsZ� <br /> Street Number Direction tree[Nam CI Code <br /> HOME or MAILING ADDRESS (If Di/ffe)ren�t fr/pm Site Alddress) v Q/ <br /> 5{>hEWA AL174' YV �4i EtL Street Number ? �O/ �10 F6 <br /> CITY ?40 i Az %S6?- 4'09/0 <br /> PHONE#1 E". APN# LAND USE APPLICATION# <br /> (66 ) x'69-3527 <br /> PHONEY Ex. BOS DISTRICT LOCATON CODE <br /> (&g) 48G 801! <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CrtEcu if BILLING ADDRESS <br /> BUSINESS NAME <br /> Li%/•vEe �o�vs��u�o�v �c �o GZ�/-/98S <br /> HOME Or Su <br /> MAILING ADDRESS FAX <br /> S��_ 0 dw /��!/ Z'o e�E ZDD c /6) GZS-09// <br /> CITY ��//� STATE CA ZIP 95677 <br /> $ roperty or business owner, operator or authorized agent of same, <br /> > <br /> m a TAL HEALTH DEPARTMENT hourly charges associated with this project <br /> N W <br /> m o m t y 1hIS form. <br /> Q Q o > Z ❑ <br /> ❑ ❑ 2, 0 El5 Nork to be performed will be done in accordance with all SAN JOAQUIN <br /> o Vs. <br /> n ..o <br /> O c - M DATE:Ir <br /> Z/ <br /> n y ¢ <br /> 15 0 <br /> 6 If Outa ni Nutho) Postal Service'r. <br /> o m -2 CERTIFIED MAILT. RECEIPT <br /> z M1 m app m <br /> a m � � I all t r1i <br /> (Domestic e <br /> my,No Insurance Coverage pro <br /> m a D <br /> m $ $ MO ALTH S <br /> m . r C3 nI <br /> ED <br /> W Y 0 4 <br /> a m ❑ ❑ IIPostage $ <br /> v OE a <br /> Q Co ci N .2 O Certdied Fee <br /> 0 <br /> Oru ¢ O Return Reciapt Fee <br /> N C3 « (Endorsement Required) Nene <br /> C3 0 C3 <br /> E Restricted Delivery Fee <br /> N I 1 f� O (Endorsement Required) <br /> d C 1' <br /> m <br /> a > 6 i � ru Total Postage&Fees <br /> E <br /> �'E <br /> $ E C3 <br /> o � dD � SX <br /> U.Nt T . <br /> O m i — fY11C t1A� C2t'Yt>• � tlt'+ct' C.nr�c+Y t <br /> F3Y 6 M1 i� F.........................._! ._?Yl.. <br /> `a E X o _ orPo Box Na. 4,[l.�- �KCG1.1j..R�: ST-C 200 <br /> vm O Is I, _ to" GN• rate. O .. .. r................. <br /> N J 1 V Or <br /> N 6 J <br /> o 'V i .2 O <br /> « a Ej Check# Received By: <br /> E « 1 <br /> N Q v s 0� g <br /> G <br /> Cl) SR FORM(Golden Rod) <br /> t« m O <br /> EEC5mo yy W <br /> • O 0-C O 1' 'w V y <br /> cJ«a mao �,; a <br />