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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST y4eDp`���ljl� <br /> Type Of Business or Property 0 <br /> 0 <br /> 23YOe SER'JILE�IF S,IP <br /> One-Eq OPERATOR c p02 �2�(� oc5 <br /> �-1 _ ('S_ C/IF[TIIB Lt fA eeYV <br /> FccNtYNa:'F P ' <br /> SITE AOoaEss <br /> tr � ,i—:vvmm.. o...a„ .�Jb(r.<ds ec SrCF.,e%• �'�ylj <br /> HUei Cr Il,Lt16g ADLgESS pl0lflnom tram SCP addreasl n� , <br /> STATE ^(IR <br /> P",Eal ca. APNY <br /> t 1 LGVa USa lJaL1[A`iC115 <br /> PH0.:Y e2 4r. <br /> I I 605 SSTq:C: L0:>nnII CJCE <br /> REODESTOR CONTRACTOR/SERVICE REQUFSTOR <br /> CnEa it an Ll.•;a+^>• <br /> e981-ass NafaE <br /> HEMI:erltAlYila ADORE$$ We <br /> QrY <br /> STATE ,AP <br /> BILLING ACKNOWLEQGEh11=NT: 1, the undersigned property w buainesa'owneq oPonl or or authori:so agent of same. <br /> ack'OM'dge that a.l site and]CT Projed aPed5c E eRON_SNTA.HEAT CE=ARnVEra Murty charges aucciatad Idfn this Pralrl or <br /> ac"'Ity-Vc bo b31ed tome or my business as Ideruiec on this form. - - <br /> I also cea;fr mut 1 have prepared;nis applica'ion and:hal IhE Werk to oe psrfamed w1A be done iC ,G,,,da....vith all$u:Jawual <br /> CC Nn Ordinanco Codes,Steadards.STATe and FE0 ax laws. <br /> APPLICANTS SIGNATURE: /��.�. DATE: ZO <br /> (/ <br /> PROPERTY/BUSINESS 0VINER❑ iF]i.LTOR/f,Ua'/.GiH nr <br /> I:AFP4Ccvr bs na fhe 2+?�evn PaRTy cFr/oerolr�a u'horOatfoo osignWls0.iegwrredO Tfrtr <br /> Al1TRORIZATION TO RELE EE INFORMATION:N^.1Cn applica]e,1,The owner Or cpemtor of the Property lTM,oCEEdat tf1E Ehuva <br /> Site address,heleb'aRFL IRs rete <br /> S ase of any and aR resul:E.gso:echeacl us,andior environrnEnl3Csllo assessment Inrormetier <br /> :o:he SAx Jo;amry CQu.Tv Elwees•.tElnu HEUTR D-P.Tr rf r as seen as it 6 avallah!e and ai the s,me dmm <br /> e it Is pmv.ded tae u <br /> my re�0.senladvc. ,,.n Ai <br /> ,a <br /> TYPE OF SERVILE REQUESTED: c S�.I..r�ILA' �YMF'•T <br /> � <br /> N? <br /> 04 D <br /> 41, UN <br /> zTio COU <br /> ACCEPTED BY: �3t I EuvLarEE 9: Due: NOfP met <br /> AssoNso TO: (3 <br /> O EMPLCTEEii: D,., r <br /> Date Service Completod (u mread)ca;nPletec(: I5Ep><r Coin: D <br /> Fee Amount: PIE. jLpOZ <br /> AmpuntP / rdZ> Payment Date <br /> Payment Type Invaic.# Lha k w�T <br /> 633 I Recei d 6y: <br /> EnD 40-02-025 <br /> DT/ILDa S=FORA, r - <br /> f-+a'Jgn qnl <br /> I: <br />