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' SERVICE REQUEST 0 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0oZ� <br /> OWNER OPERATOR 8u UN PARiY❑ <br /> FAciLaY NAME <br /> S[TE Ail0RE55 <br /> s�;r•rs <br /> Mailing Address (If Different fFom Sita Address) <br /> Crry ��/� STATE ZIP <br /> r � <br /> PHONEr1 <br /> Err. APN# LANaUSEAPPLICATION9 <br /> 0-C`-f <br /> PHONE#2 Ur. SOS DISTRICT LOGITIOH COaE <br /> CONTRACTORI SERVICE REOUESTOR <br /> EG <br /> BU-M PARTY�QI` <br /> PHONE Ela � <br /> Y r 9. wc- 9�6 ���r X66 <br /> s ' Jam[ FAX# w <br /> GEB V t STATE. <br /> BILLING ACKNOWLEQGEMENT:i, the undersigned property or business ownar,operator or authodud agent of same,admawmedge that all she andfor pn*ct speck <br /> PUBLIC HEALTH SERY]GEs F.riv ONMENTAL HEALTH O VGM hourly charS%associated with pts proper or advity will be b+'led to me or my business as idenffiied on ags kum. <br /> I also car*that I kava pro . p and that the work to be Wrtonned vrJ be done in aeaxdanca with aA SAN JOAOUer CourrrY Ordmw=Codes,Starx*ds,STATE and <br /> �FEj'OERAI Iaws. r <br /> PRGvERtYIB4SW-SSOWNER ❑ OPERATORIMANAGER Q OniERJnlTHotal=AGENT Q ^ <br /> YAartrra no[G�HJI�lP�proof of authartraUon tosi�e h nqurMd <br /> Title <br /> A—MORIZATION TO RELEASE INFORMAnON:When appkable.L tho owner or operator at the property located at the above Bite address.hereby aut utw the rejam of <br /> any and all mSutts,geotedtnica data aa:Vor a AonMeAWJ3 to=033( 1t infpr;rratipn Oa 00 SAN JWUN GOWM PU&X HEALTH SERVCES ENVRONmENTAL MM-,H Dm=N as soon <br /> as A is available and at the same ebur it is provided 17 me Of my represesrta m <br /> TYPE OF SER=E REQUESTED: <br /> &hZ6I <br /> COMMENTS: <br /> �T�X? (^` __ ��J ,�4,y�"- ,..�°a°'�' �' • Com' I A+�t:r-- V�k�w stfu, �C�f`T µ�5s, � t-- cru <br /> ` J �[�� tti7kVvCsl.WcrwS4'Gv, t 4C ��� Com• <br /> t 't u QPWr--v IV=8xv. k(S 1451 R 11 <br /> 1 <br /> 9/1541 <br /> �� SAN JOAQUIN COUNT' <br /> EN PUBLIC <br /> N <br /> PU LI HEALTH H SERVICES <br /> fAL HEALTH OIV�S <br /> INSPECTOR'S SIGNATURE: lT — COXTRACTOR'S:iiGNATU <br /> RE;: ; <br /> APPROVED BY: ExpL.OY`r'�„t OATS: Fri EYPLOYE0. L' DATE: <br /> Date Service CampietELd•{if already completed]: 5t7tvtc> CooE; `1, 0 3 i/" <br /> Fee Amount: n4(2-- , . 1 <br /> Amount Paid -� Payment Date 1� <br /> Payment Type v.�� in+roic2# Check E; 3-L Received By: `� <br /> s -s. <br />