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EN <br />SAN JOAQUWOUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Typeof Business or �Propperty FACILITY ID # <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESSNAME <br />t -t1 t L.i C.� -� CTCV I;.i S ; �Z✓ i� 1 r <br />DATE: <br />b y <br />o L <br />La 2 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />'� �t'�✓ <br />CITY_I c /v <br />STATE <br />FACT TY NAME <br />�'�s� <br />Payment Date <br />3/ <br />SITE ADDRESS <br />Invoice # <br />LACj..i <br />