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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR i mEiv i <br /> SERVICE REQUEST <br /> Type of lousiness or Property FPcn ITV In <br /> Ea c v-ct c <br /> 1 flu.ucq i flgcgw-rnq n i <br /> FACILITY NAME <br /> �I Y"l 4th I I �� Cz et4(T�c� '�� SSG(CtiW1 <br /> treet Number Direction L Street ame C' L Code <br /> NOME or MAILING ADDRESS (I ifferent from Site Address) <br /> CITU -�� STATE ZIP c7 <br /> o..,....x� ._ ExT. 1 A DhJ« I I ....,Igo,A..... �....... I <br /> PHONE u% EXT. + BOS DISTRICT LOCATION Cr)DF I <br /> i <br /> I I 1 II 11 1 <br /> / Co fNrl KAk-I VK/ JC.KV luin Kr.tlur... : <br /> -R uHECK 11 BBI I IPG AnnRFSSL.J 1 <br /> flrtuc nr MAn tuc ennoccc ( FAY It <br /> CITYIC. � clot/C � TATt <br /> aC:......... t.. I__. ..�.-=tai Lt�ViR�JNfv GI1TtL$IEALii. £�ARTflE�T Otl C� lg" a _.», k s✓litt t?ais jSA'Ca)CCt <br /> ot <br /> Al)THOkl/.AI110N 16 KIPAX.A1r. �i�rvJKwv a ....,.. a ,.., ........ ,.. ..... ... .... .v Q°3iQ iiK'ia'F;: r:4 w.. <br /> IRI:._-;..: ._. . .1- [`... i,.........lam... ...-.. r.................. ...... .... ri. .. ....... .. . . . -1� i -.... .'... .. _ <br /> i <br /> JUL 1 1 1017JOAQUj <br /> Z— —7" SAN ENVIIRONMENO NTY <br /> HEALTH DEpgRTMEN1' <br /> I ArCFPTFn f 1 I �-Mn,Hurt 1V. I (..rte. <br /> 1-7 <br /> -7'al 1- <br />