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SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> BILLING PARTY L <br /> OWNER I OPERATOR <br /> FACILITY N a 11 <br /> �- tlrY. P�caL <br /> de �o <br /> SITE ADDRESS Str.0 xfnra Try. surtaf <br /> sm.t Romer olrkdan <br /> Mailing Address (If Different from Site Ad ress) I r <br /> 3 1 STATE Z:P t Q <br /> Cm p � ,J <br /> Ln �. APN# LAND USE APPLICATION# <br /> ('400 <br /> PHONfE`#t <br /> — BOS DISTRICT LOCATION CODE <br /> PHONE#2 Exr <br /> CONTRACTOR I SERVICE REQUESTOR <br /> .� BauNG PARTY❑ <br /> REQUESTOR <br /> P # En. <br /> BUSINESS NAME a S 9 <br /> FAx# <br /> MAILING ADDRESS I <br /> O ATE ZIP <br /> Cm l C,g <br /> BILLING ACKNOWLEDGEMENT: i,me undersigned property or b 'ness ovmer,operator or audl agent of same,adlnawEdge mat all sila and/Or project spedTx <br /> pUaUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hou charges _ with CIa protect 0r auvdy wnll be billed m me or my business az identified On Cls bmL <br /> I also arafy mat nave prepared this appfiraEon and That Its m pedomred will t>a dofinrz wdUT a0 SAN JGAouIN CWHn Ordinance Codes.Standards,STATE and <br /> FEDERAL IaM- <br /> DATE: <br /> APPUCANT SIGNATURE: <br /> OPERATORI G ❑ R>ffD AGENT ❑ <br /> PROPERTYI BUSINESS 0;"ER Title <br /> HAPPA.WrTsn m& of fudA dan cosign cr .d <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.L me ovmu or operator of me property located at me above site address.heretry aumonm me release of <br /> any and ad reSutts.9e0teChnical data andlor emimnmentaUs�assessment infOnnatiOn m m0 SAN JOAOIAN COUNTY PUaOC HEALTH SER`nCE3 ENVIRONMEMu HEATH DrVLs:G+f a5 scan <br /> as I b available and at me same dme d is provided m me or my representative. <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: <br /> INSPECTORS SIGNATURE: CONTRACTOR's SIORATURE: <br /> EfIPLOYc�}f: DATE <br /> APPROVED BY: <br /> ASsIGNEDTO: C EMPLOYEE#: ��'g O DATE Z3 D 2„ <br /> c� SERVICE CGDE: PIE- 23 Q 3 <br /> Date Service Completed ('d already completed): 3 <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type Invoice# <br /> CReceived By: <br /> Check <br />