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' • <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10 9A a —� SERVICE REQUEST <br /> S ST lG� V <br /> OWNER I OPERATa WeS� COC4 Pr4Uc4; LLC HIL NG PARTY❑ <br /> FAcluNMCME A� <br /> slI>_Ao���S Zai 1 b NJ M �N I-I,a(.rt - <br /> Nombr otrtdon SarNt NxtN T.T-n. Sulu; <br /> Mailing Address (if Different from Site Address) <br /> CrFr STO c k-ToN cA q S- - STATE zip <br /> PHONE#I aT APN 4 LAND USE APPLICATioN 9 <br /> fZai)lt�- � - SSsZ <br /> PHONS at1 Err, SOS Dim= . Low*N CODI: <br /> bio 6��1 - gctq l <br /> CONTRACTOR SERVICE REQUIMOR <br /> RE9UESTOR A �� BIlIQK.PAKiY <br /> BUSINESS NAME /�j` PHONE# �T <br /> -Fe co►� cl��,olc� es Ihc . 10 "q t <br /> MAILING ADORessI <br /> b I g S, To le i-,onj A ' FZiIO 6 4 <br /> Crrr H ci W 414 0i''r�-Q— - s�TATE CA- ZIP q D -Z5D <br /> BILLING ACKNOWLEDGEMENT:I, the unC"ned property or business owner,operator or authortxed agent of same, ackr�e that aA sIm andv Pried s,*cRc <br /> Pueuc HEALN SERVKEs E.wncmENTAL HEALTH Orvt5I0N Wwurty utas assoaated vrith thR Mj6ct or amvq w0l be Wed to me or my busincss as fdentif*d on this loan. <br /> I also u rjt y tnat I have prepared mE application and that me work m he pertorfied veru be done in accordarrce with all SArt JCAWIN CCurm'Ontn&we Codes Standards,STAT-8 and <br /> FEOERALfaw9. <br /> APPZ.1W SIGNATURE: U p DATE: + ./ Z' vim"za7:!L <br /> PROPEATYtBUSINESSawNER OP.JUTGRIMW7--rt ❑ OTHER AUTHORZED, AGENT Cl <br /> ff APFLr-twit nor rhe 6tLt4 pn proof of nnAarfndon to sign!r mound Title <br /> AUTHGMZATION TQ RELEASE INFQRMATION:when appl�le,l the owner or operator of the property ioraeed at to above slur address,hereby autoriae the release of <br /> any and all resulm geo"nKmI data anelor ermtwurtenaUsce assessment information to the SAN JOAauw CouHTy PuuLC HE 41SH SSS ENARCAW-NTAL HEALTH OMWN as soon <br /> as I is available and at me same time d is provided to me or my representative. <br /> TYPE OF SERVICE RMUES ED: I <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVE® <br /> mov <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> I.NVIRONMEN"RAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY. Ex>'>z DATE: <br /> ASSNCNtDTo: EMPLOYEE 9. --1, b DATE: aZ <br /> Date Service Completed (rfah-ndY completed): S £Cooe -k 4.(0 PIE: ?304- <br /> Fee <br /> Z3040Fee Amount Amount Paid Payment Date � ' / 4 y <br /> Payment Type Invoice Check it ��Q Received B),• �� <br />