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^ M <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 41200,�22_10 <br /> Type Of v�usiress or Property / <br /> , fACIUlY ID e <br /> I t 5ERV�I1tCEREOUEST[ <br /> tTynE DVEggiDR �� <br /> Vs Brass,, G[O itae ra_ AD Ea� <br /> FAam NAVE--- --- <br /> Dteaski"S - cf--lam k- <br /> SRE AOORtsa <br /> So I let' $t fsl y. 9as � 9SNsa <br /> HmEa MJapIp f <br /> OAOOpf Oiffttmtfrom BRa AOGsael ��,� C� <br /> (j/ cY . <br /> Cm <br /> IMOrt it [n, ,tpHp Larcp Use APPru.•rlora <br /> (9k1 fv.2- oN7e! <br /> pmxf2 mr. BOS Ooralor <br /> A, NNG.-6r23 <br /> REOVESTOR <br /> COMMACTOR/SERVICE REQUESTOR <br /> Qa/� <br /> ,..Somm"a CaEpa ttEntnro Avoara, <br /> BUPNEsf NAME , Q_CA")r <br /> gOe1a m. <br /> HONG orhlN oADDRESS dot& vex5/ <br /> CIT <br /> An <br /> V P Jut, <br /> O. 9I-' D <br /> acr SureLs <br /> BILLING ACKNOWLEDGEMENT: 1,the underslyrkd property a business mvflor, <br /> acknoMedye Net an site Anwar pmjW specee ERVIPavuaxTAt HEx:rl DerxanAxr Mato[a authorized agent of came, <br /> actInty V-9 be bided W me a my business as IdentUhed on Ws farm �'chwOes ASSOCeteo u1N W3 prooct a - - <br /> �a. <br /> 1 also Certify Rat 1 have prepared Oft ep readon and dot Uro vaM to be ~L . <br /> Cp Oveenarce Cedes.Smndanh.STATE end FaoERu in". ped0med MA be done in ecmda:,:o W ans",JejOu n <br /> APPLICANT'S SIGNATURE: DATE. ��L,��TJ• <br /> PROPERTY/Bun:ttsa Oar.E t7reru:oR1MAR•c[R ❑ OrntRAMano[o Ao[nn ❑ Ow Iter— <br /> HArvtrun:hrro7 Na� rnvP�An prop/ofaufAorheNon ro s/gn fa re0v/hd rrH[ <br /> AUTIIORILeTION TO(LPI h^^ :KTan 20FRpby,1,the owner a operator of ted ifo <br /> alta addrna,hereby auUlor¢e We rgesse of any add e0 ranula,"Olil kal data etWw amtrDrmerl•xV IEM assessmentrty;ACA:Ad llnfDEmpdona <br /> mry mpresamatNeted SAH iJvOv. CWlry Fiargdp,yv<ru IIEx7 DsgyyOr;os Doan As a b aveuabfe end At Da;same thm R is provided to me aTYPE of AqY <br /> O"nSEayKE RFOUESfEO: j� �FC A�HT <br /> COrs[ms: �-�- - ✓ N� �Y o <br /> ACCEPTED Bv: ENnavee Q: A1� <br /> ASarrHa TO: - Elrnom p: <br /> wE: <br /> Data m..SorA.O Complotad Ielnadycon,,,jetadj: SEA txe CODE: <br /> (�" PIE: ' <br /> FeAmount Amount Pal <br /> Payment Date r <br /> Payment Type �� Invoice S <br /> Re Nod <br /> EHD1a-0242d <br /> OrHriOa SR PORN IUDlden Rad) <br />