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SAN J0AQU1h.,r.0VrM EWIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Busineta or Praperty FACT ITY lm M SERVICER_,_ STS <br /> t <br /> 52OCib '_'> � � <br /> 0MrELIP7ERATOIR <br /> SrTE Aowmm s , f <br /> C J'� C� rL� � r �4 <br /> HOW of MAAaa;ADDRESS tit WlTPaent ftM SM Addesemul <br /> wnc�r <br /> Cm' STATE J'Jt' <br /> 1P1'�rara/1 <br /> Ev. ApR/ <br /> io—M <br /> :7T— <br /> CONTRACTOR <br /> Peoma R E^ LACAnon C:o1E <br /> I 1 <br /> / SERVICE REQUESTOR <br /> RE ESTOR AiCKr ® <br /> •1 Er. <br /> Bu3mEss NAME2 Con` _ i C f <br /> HosmE or ADDRESS FAX _ <br /> f 1 <br /> STAY <br /> cmr r �.�� <br /> 811 L NG ACKN9WLEP L31, N : 1.. the undeICA <br /> rsigned property or business owner, Operator or nNrtrrtraed spot of lama <br /> a:.knowlrQge thad all cite mid tw project Specific ENi'tK0NM trrTAL HFALTtt PEPARTmi-Ni hntuly cf arip m associated with this project <br /> or activity will be billed In meor my basmess as identified as this form_ <br /> 1 also ccrti fy that I ha•a Prcpertd this aMl icatnon and that the wo6 to bt performed will be done in=rx donee with all SAN JOAQM <br /> CD(*M(Witwwr C'�_aks,.Saurrd rrdv.ST/AY ^,arK3'F trFRAL laws. <br /> APPLICAh"T`SSIGNATURE: i G. 1yr�J gwYC. I L <br /> PxoPERrnllM.M4Mc)%NiR❑ "n5L%T(W01"%A1GEa❑ nt«Ea AlIM ILEI/A4E4T <br /> IfAPPtx'tNT i.n r $Owfiar4+ FakT) ProOJaJantkoriratlnn to sign is myrfseat trNr <br /> At'THQK19A-rION-ro RELEASE INFOf&MATION When applicable, 1,the awoer or operator of the property bested at the <br /> above cite address, hereby autlwrize the release of any and all results, gcott.,thnrcal data anchor envirorunetn lysim AsSessmcni <br /> information to the SAN JOAMIN Ct}tIN1Y E-NVtRONME%-TAL IiEALTII t>TTARTME:NT BS SQ(M as it is available and at the same time is is <br /> provided to me or my rcPreaenntativt. <br /> TTPe OF SrJryU REMSTM; , C r ) ` - PAY , <br /> RECEIVED <br /> JUL 2 3 2012 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONME <br /> TH DEPARTMENT <br /> ActaoTm _. ErPLOPEr/C •,b ! - _ DAnt- lv <br /> Assa3nEo 1'O• EaPc,DrEs 1i. �I: / _ �' OuTe le...-. <br /> Date Service (Y alreadycampwe): STRPCtCIM Pie y3�� <br /> Fee AmpUnC 7P o Amount Paid -- / <br /> Payment Type LJ /nn�,,, tnvoita# Check 4 Raosivad Isy: <br /> END 48-W4= lden_ l y oC [ L SR FMM(GoRaM <br /> REVISED tel tM0011 <br />