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+der R <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST rt <br /> OWNER I OPERATBLUNG,PARTY <br /> FAcit.rl Y NAu e r <br /> SrrE ADDRESS <br /> 2,L-3L4) / V T1 str..c71wnn.r Dtrwwn 3a.rsame . �Yv suits <br /> Mailing Address (If Different flom Site Address) <br /> crrY l rf f- G c STATE/% - JS <br /> PIiOHE#'1 ur• TAPN# LANO USEAPPUCAT70. ,, J N' <br /> ( v �3.Z - 6�Uo <br /> PHGHE#2 err. BOS DMIICT LOCATION 60E- <br /> CONMCTOR l SERVICE REQUESTOR <br /> REauEsTDR BULLING PARsr C <br /> P <br /> t PHONE BUSINESS NAM o� <br />' <br /> MAtUNG ADop= FAX 9 <br /> CfTY .P C'' STATE �1'� ZIP s- s <br /> BILLING ACKNOWLEDGEMa=NT; f, the undersigned property or business owner,operator or authodud agent of same,adTa'riedgo that au me andfar project specific <br /> Pusuc HEALTH SERVICES ErfmcNwENTAL HEALTH OMSION hourly larges associated with this project or ac:h*wid be belled to me or my business as idtntified on thins fom <br /> I also certify that i have peapared this appGgtion and rk to be rmed v el 6o done irva`cxxudarx a WE h all SAN JOAQM CwrrtY Orrfinenoa Codes,Standards VATE aced <br /> FEDEAAL laws. <br /> i /X APPLxurT .NATUPZ DAIS <br /> I ` ` <br /> f <br /> PROPERTY 1&MINESSQwNER Cl CaERATORfMANAGER ❑ OTViMAUTHGFaEoAGENT ❑ <br /> XAVPucvrri30XftQ1LMJ pvdaf Trorwowrosgr,bM9W*d Titre <br /> k AU'T'HORIZATION TO RELEASE INFORMAT12N When perstotottha <br /> appie�bia.L the cvrrter ar a property opted a2 the afwve ails addrsu,hdtby autltal>;a Lha release of <br /> any and all results,grate:hnieal dam amUw e(rYitOnmlattaVsila aWanment int atradon to Me SAN JOAOUet COW"PLUX HEALTH SERVICES ENVIRONMENTAL HMTH oNtsm as XW <br /> as it is available and at the same tlmo it Es pt Med to me.or my mptesartatim <br /> TYPE OF SE M-E REQUESMI: y <br /> - G-- <br /> coacxr:Hrs: <br /> PAYMENT <br /> RECEIVED <br /> f <br /> 0 � APR 2 9 2002 <br />+ SAN JOAQUIN COVIN 1Y <br /> , PUBLIC HEALTfi SFRVICFS <br /> INSPECTOR'S SIGNATURE: v CoxTRAcToR'SSr ATuRE: `N"HOWNFAL HEAJJh UIVISI.,.' <br /> l APPRovED eY: ©Ut v f -4 EmKZY=� ®3 24 DAM <br /> ASsIGHEDTo-. Em?LoYEE#: DATE: <br />' Date Service Completed (rf already campicted): SER►rEcz=Gaol: �c-2S P[F. ZCa. o� <br /> Fee Amount: cFS c�7 TAMOUnt Paids _ payment Date 41L9 aL <br /> h <br /> Payment Type Invoice# Chec" 3 9�� Received By: <br /> i, <br />