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..� SERVICE REQUEST <br /> T <br /> FACILITY IDT SERVICE REQUES <br /> Typeolf�9usiness or Property ! � <br /> A I rz BILLING PARTY 1] <br /> OWNER OPERATOR <br /> 11,',,AD A ST�1 <br /> FACiLfTY NAME S PA n <br /> 7-A PA sF ,�o.�l <br /> STTE ADDRESS -,,,A J - <br /> ^ _ 51nA Hame �r°e Suits I <br /> tJ��L. Strep Humor Dir--tan <br /> Mailing Address Of Different from Site address) <br /> STATE ?IP <br /> CITY <br /> C LAND USE APPLICATION# <br /> PHONE 41 - APN# <br /> BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> CONTRACTOR 1SERv10EREQUESTOR <br /> BILLING PARTY <br /> REQ(IFSTOR <br /> DON C�� S�IE PHONE Fps. <br /> BUSINESS E /��j/ - - - 74'.r U <br /> MAlUNG AD DR SS <br /> O 7 STATE L A ZIP <br /> Crry I—ap L-o6z <br /> BILLING ACKNOWLEDGEMENT: I, the uneersigned property or business owner, operatoroof aC ty ill be billed to me ogent of r business as dendfised on thisrform.ect sped6c <br /> PUBLIC HE.-tL-H SERVICES=:IVIRONMENTAL HEALTH ONISIDN hourly Ctlatt3e9 a550Coled with this pro) <br /> ect also certify that I have prepared pplicatlon and a work to be performedwill <br /> be done in accordance with all SAN JOAOUIN OCUNTY Ordinance odes. Stanoards,STATE and <br /> =.DERAL laws. DATE: <br /> APPLICANT SIGNATURE: <br /> OPERATOR I MA cR O�,11=�QEGENT Title <br /> PRCPERTY I BUSINESS OWNER 13 Y�vOcwris not the aLLz P.ary.drsign is npuusd <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I.Ile owner or operator of the property located at the above site address,hereby authorize the release of <br /> an and all rasultS,9eoteUlni(21 data andlCf anVlfcnmentaUsite assessment <br /> �2 Cmri 3ntltVlenfo mabnn IO the SAN JOAOUIN l,Ol1N TY PUBUC HEALTH SERVICES CNVIRONMENTAL HEALTH oNISIDN a5 soon <br /> Y <br /> as lis available and at the same time it is orovlded to me or my p <br /> - <br /> TYPE OF SERVICE REQUESTED: ^ '/ T(Z A-T F <br /> COMMENTS: I <br /> j <br /> CONTRACTORS SIGNATURE: <br /> INSPECTOR'S SIGNATURE:/ I DATE <br /> EliPLOYEE#: <br /> APPROVED SY: i DATE: <br /> :MPLOYEE <br /> I ,ASSIGNED TO: <br /> SET/1GE CODE: S�S <br /> it Date Service Completed ;If already c pleted): I Payment Date <br /> Amount Paid <br /> :,!e .%mount: 11 mount: t Received 9y: <br /> # I Check# <br /> Invoice <br /> Payment Type <br /> �Urnfh a/�/G, ,� � ' rlVNr JEFT <br />