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• • <br /> SERVICE REOUEST <br /> Type of Business or Property FACILITY ID# T <br /> STT 9'WLI. CC-Ij_Z7�Ii7 �Jo of J9Sc <br /> OWNER OPERATOR SLUNG PArwk <br /> 1009 '-1 LCIS <br /> FAcRIry NAME <br /> L D <br /> SITE ADDRESS <br /> I.07�6 <J S�iwhN7une.r WKtiar se.ueam. Tn. s.n.. <br /> Mailing Address (if Different from Site Address) <br /> 101 L0uJL'Zl2- . 6]N'0 RID <br /> CITY STATE ZIP <br /> PHONE#1 eaT• APN# LANDUSEAPPLicATaN# <br /> ( I C�57— ��1. <br /> PHONE#2 aT. BOS DISTRICT ; .. `^' LOCATION CODE - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR --r- <br /> SLUNG PARTY❑ <br /> J i m Loopc t' <br /> BUSINESS NAME PHONE# �• <br /> �Q I <br /> MAwNG AooRESs FAx# <br /> CRY STATE Zip�-� 1L f� rl � 2 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or lousiness owner,operator or authorved agent of same, admamedge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ONAIENTAL HEALTH 0 hourly charges associated with this pmlect w aaMy will be bt0ed to me c my business as idenMed on this form <br /> 1 also tardy that I have p this application d the work m be perfemhed will be done in a¢wdance with as SAN JOAOUN CcuNrY Ordinance Codes,Standards,STATE and <br /> FEDERAL taws. <br /> DATE: <br /> APPLICANT SIGNATURE: ,./ <br /> PROPERIYIBUSNESS ❑ TORI MANAGER ,Cl. OTHER AUHORDFD AGENT ❑ <br /> CARl.Cw7anof UN911 PAPTY'prad of audwtution to sips Is npuead Title <br /> AUTHORIZATION RELEASE INFORMATION:When apprimble,I,she armor or operator of the property located at the above site address,hereby autharim the release of <br /> any and all tesurbG g technical data andfor envI00 nmYsi a assessment Inf un bon m Ne SAN JGAOUN COUNTY PUBLIC HEALTH SERVICES FIMIiONAFNTAL HEALTH DmswN as soon <br /> as I is available and at the same time it is provided to me or my representative. 1 <br /> TYPE OF SERVICE REQUESTED: � � IPbTALi- -0 DIJ ?Lr1T� <br /> COMMENTS: <br /> PAYMENT <br /> p�R fE�Ccc��EIIIVED7 <br /> APR Ar 6 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMEWAl HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: R'/ CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EwrL-cy—aS: - DATE: <br /> ASSIGNED TO: 2n-1-7 gL � ' EIPLOYEE#. O0 DATE: /�G —O <br /> Date Service Completed already comple ): SERVICE CODE: P f E- <br /> 3,:63: <br /> {d <br /> Fee Amount Amount Paid Payment Date t5 <br /> Payment Type Invoice# Check# D 7 Received By: v <br />