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B-25-1998 3:58PM FROM P. 2 <br /> . ., SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 0 �j I til SERVICE REQUEST# <br /> OWNER OPERATOR� n BUNG PARTYX <br /> SITE AOURESSWG-S� L-.c,- "�-Q__ �IOCk,lv11 <br /> 4714-1 m..�,. 9'� Nr ' Ta S .a <br /> Nailing Address (If Different from Site Address) <br /> 9.0 . 6o X DO 4 <br /> CITY 5A, Rc�n � STATE CA za 9¢583 <br /> PWNE#1 W. APN# - I-Am UsE APPucATxw# <br /> RZ51 844 gOOZ 104 - 370 - (O <br /> PHONE#2 Exr. 80S DMTRIcr LOCATION COOS - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUFsyoa Blurt PARTY❑ <br /> JGow�- �O <br /> BUSINESS NAME {-� PNONE# eT- <br /> �HL vLS vac. 10 76S- 660 X24o <br /> NAILING ADDREss q GAx# <br /> n f // 'No � Dawe 11 L3 (v,1 707 765- '7'10s ,/ <br /> crrY f(n4el t.f�41 - l STATE CA- ZIP /4' /- 4- <br /> BILLING ACX QjnEDGENEtQi: L the undersigned property«INaineSS OWne,Operator or audrariwd ago#M same.3dmowedge'191 ab 3k and/or P*d Wetr'c <br /> PUBLIC HEXTH SEmnCES ENVN4waEMF1 HEAI-T)l Otvlslvr hourly dlames assO®tN wm tae project«eclNhy vdl119 bled to m•«my mistress a identbed on Elis OOrnt <br /> 1 also tp y Ipt 1 have pceparad Ile epp6c36on and Etat ft work to to d be done in a=dance wth al Sw JOACKM COUNTY O(d5N&xI Codes Standards STATE and <br /> FeERAL Ian. 9/ <br /> ApOIaCAIR SIGNATURE: OATS f <br /> PROPERTY lBt69IESS OWNER ❑ OPERATORIVANAGER ❑ 0n#ERAufHOal2rOAGVIT <br /> IAPPGCWrisndlaftM9Daf'P a*f 11 1 4 I*S*lt Ti!!e <br /> AUTHORIZATION TO RELEASE INFORNATrOK:When appkahl9-L d1e wmer«Opema r d E1e property located at Ere*have*dn add v hereby auelorto 1119 ralanne of <br /> arry and a.msUtls-geoterJNli®I dam ardt«eRYimMIBrCalsim assa4vrled cdarRNOmI m 1118 SANJOA"COUNTY Plm 1167 SERY1tf5 ENvrNtrorBrfAL HEALTH DNOM as sow <br /> as d'a avaibhN and at the same time i is provided m ma«my mye3axalIL& - <br /> TYPE OFSERvtCSREcu*vED: Ont �or� n nom' \` 0. a 1^, <; <br /> —5-v.s�k1 Soo <br /> �PfAY^MfENT <br /> SEP 111998 <br /> SAN JOAQUIN COUNTT Y <br /> PUBLIC HEALTH SERVICES <br /> INSPECTOR'S SIGNATURE CONTRACTOR's S1GNA7u;E ENVIRONMENTAL HEALTH DIVISION <br /> APPRmr®BY: EfPICY«1F I OAT—' <br /> ASs1GNMTO: (�. EwLarEE#: DAT£ <br /> Date Service Completed (If already complaW: SER111MCOOE C 'P I E <br /> I"Amount Amount Paid `rj PrymentDate I <br /> Payment Type fnvaint 0 w R ed - ltiWf� <br />