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Type of Business or Property SERVICE REQUEST <br /> /d FACl/Ly-I��TY ID# " 3' .., <br /> SERVICE REQUEST# <br /> OWNER OPE OR F" ' ©oc <br /> 8 ] 3 <br /> �es '(Qe <br /> FACIffiY NAME S > o„� '�- �,,/ BILLING PARTY <br /> R y� <br /> SREADORESS <br /> /-/ w <br /> Lv y <br /> h,or ry address f Different fro Site Address) — sux m, <br /> OX O o , Trp, SWb1 I'- <br /> CITY / <br /> e-5 • STATE LP <br /> PHONE#1 C, n <br /> ( APN# LAND USE APPLICATION# O�y <br /> PHONE IYLEr. ' <br /> SOS DtsTRIGT <br /> -1 lrv:ti I LGGATION CODE f,'?, <br /> REQUESTOR <br /> CONTRACTOR I SERVICE REQUESTOR <br /> ,,// /� <br /> �e� ,�LISD,(Q BUMG PARTY <br /> BUSINESS NAM //�y 'L/� _ / <br /> L . LCI 765 L_"_� <br /> MT G�I���`O ry PHONE <br /> AILING ADDRESS S <br /> 1 n3 !1 CO./%IQ C /i4/✓ � FAX# 7 <br /> CITY <br /> STATE ^_ .LP <br /> PUBLIC HEALTH <br /> BILLING ACKNOWLEDGEMENT: Ithe undcrsgncd property or busineowner,operator or anlhoried agent of same,acMowPdy c that an silo and/or RIj spedf�c <br /> SERVICES ENVIRO U T ,AL HEALTH DmslOu howdy chargs asso6ssa(edwilh IhiS pmfttj oracti ily lilt be billed tomo or my business as identified on Ihk farm. <br /> P lett <br /> I also certify Nal I have prepared this application and that the rk to be pedor�ed vnll be done aaordance with all SAN JOACUIN COUNTY Ordinance Codes,SlandartG,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGHATURE:_�APPLICANT$IGNATVRE; � / � / 1 - <br /> PROPERTY f BUSINESS OMER `,J - [)Art: 8�y� <br /> OPERATOR/MANAGER _ OTHCRAUTHORUfD AGENT <br /> AUTHORIZATIONTORELEASEINFORMATION: RAPncwrsrrJmo PMrrpoorcraumorindonNoIimtrvquTod <br /> When applicable,l the owner or operator of the roe rifle <br /> any and all results,gcolechniml data andfor erwronmenlaVsile assessment -formatien P the SANJaanN <br /> as it is available and at the same Vme it B provided to me or my represenlativ. property rly PUBLIC E L`above site address,hereby HEALTH <br /> authorize the release of <br /> CIXINiY Pwuc HEAT.nI SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> TYPE OF SERVICE REQUESTED: V i <br /> J rI i n <br /> COMMENTS: .��-� <br /> PAYMENT <br /> RECEIVED <br /> AUG <br /> INSPECTOR'S SIGNATURE: SAN JOAOUIN COUNT'/ <br /> CONTRACTOR'S SIGNANRE: +'UBLfCfiEALiH SERVICES <br /> APPROVED By:. �In , 9 - ENVIA;i�`"�'iIAfI, <br /> -'ASSIGNED wW EMPLOYEE#: <br /> DATE: { r— <br /> j� �._-.1.) <br /> V , f , EMPLOYEE#: -, J . <br /> Date Service Completed (if already cnmpleied): 0 (� DATE: I .a <br /> S P.t".CE rCGE: — <br /> Fee AmouR(; <br /> Amount Paid PiE <br /> Payment TypePayntcnl Dalc b <br /> Invoice a' <br /> Check# <br /> Received By: <br /> n <br />