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SERVICE REQUEST <br /> SERVICE REQUEST <br /> FACILITY ID k <br /> Type of Business or Property <br /> BILLING PARTY❑ <br /> OWNER OP ERATOR L 4cvvt L <br /> Suf] _yt. L <br /> FACILITY NAME .IU` <br /> A) <br /> T✓tc-v� 62"�C-K 2� Tro. S�,Irr <br /> SITE ADDRESS 1 &6 6> s~Nrma <br /> dlracaan <br /> Mailing Addres�if Different from Site Addr��Q�� ZIP �} �( <br /> JJ STATE /` ,�I l <br /> Cm l�LIC <br /> L LAND USE APPLICATION If <br /> �,. APN k <br /> PHONE k, _ a 3» <br /> 3/-� 1 c# SOS DISTRICT LOCATION COOS <br /> PHONE rY2 <br /> CONTRACTOR I SERVICEERREQUESTOR BILLING PARTY <br /> REQUFSTORAn� I •��/'1C'o>us "T. <br /> PHONE X <br /> BUSINESS NAME <br /> _ _ -. ._.... n FAX X <br /> MAILING ADDRESS ^ / A s .0(4![�I.0 J ZIP �CO3 /C <br /> vC/ L.JY-r .t STATE �Y iii _ lJ <br /> CITY L ' <br /> or business owner, operator or author¢or actNq Medagent e trued t0 me or m bus ness as identified on this loan- sof <br /> BILLING ACKNQWLEDGEMENT: I, the undersigned propertyit this My Ordinance Codes. Standards,STATE and <br /> PUBLIC HEALTH SERVICES ENVIRONMENTaAdLjd/p/HpEALTH DIVISION hdUm(c3lafge9 as50Cateded wlfl be done'm�al�rdan�with all SIN JOAOUIN 'T p <br /> L/wGwn and that theye <br /> I also ardty that I have Prepared this <br /> FEDERAL IaVIS. <br /> APPUCANT SIGNATURE: Crl N C 1 ATA-Title o A l d/It�'idU <br /> OPERATOR I MANAGER 0 OTHER AUTHOR11E0 AGENT <br /> PROPERTY I BUSINESS OWNER Areal ar mmomadon b alpn u rWnind <br /> appquvr.s not Nle Omer orr op <br /> die.L Ne owner or operator of Ne property loafed al the above side address,hereby aunadze the release a <br /> AUTHORIZATIQN TO RELEASE INFORMATION:when applies <br /> HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a5 soon <br /> any and all results,geotecnnial data anNor enwanmentaysite assessment ro�dw m the SAN JOAQUw COUNTY PtIOOG <br /> as it is available and aI the same time it is provided to me or my p — <br /> TYPE OF SERVICE REQUESTED: 1 <br /> COMMENTS: - -- <br /> F?r' ,I: - <br /> ,lUM 2 i <br /> pUBU <br /> w,,4t4'I Lic'£HIC <br /> 'VVIR(` -. rIVISIOr. <br /> CONTRACTORS SIGNATURE: j <br /> INSPECTOR'S SIGNATURE: ( GyPLOYEE#: (�(� DATE• <br /> APPROVED BY: DATE <br /> oMPLOTEE:: i`, 10 ) <br /> ASSIGNED TO: _ SERVICE COOS r, i -;t PIE: Z(CO <br /> Date Service Completed (If site y completed): I payment Dale <br /> 'I ,- 4 Amount Paid <br /> Fee Amount: I Check x Received By: <br /> Payment Type I Invoice A <br />