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SERVICE REQUEST New <br /> ® (q 949 <br /> SERVICE REQUEST# <br /> FACILITY ID# - <br /> iype of Business or Property. O <br /> 04LI MEFCIA L � L/N BILLING PARTY -JOWNER I OPERATOR <br /> FE'AjCT[2 1/i,/C r <br /> FACILftt NAME �r p'irYlNE '/2 1--A 1!5 ..¢O VALGE /n/IPRi'iODn� sa —9 / <br /> LAwlonlTlz('tG4N1/ �A '99- 14 <br /> � �/A/2LAN <br /> SITE AODRE55 M.I Mim. <br /> DO Seen Humor dlrKJon <br /> ,Mailing Address (if Different from Site Address) <br /> STATE ZIP <br /> TPHONE41 <br /> n <br /> APN# LINO/�USEAP�PrLIWTION# <br /> lap �y '�j`?`C) .- 0 �FI ;/ <br /> J l F7 <br /> DISTRICT LOWTIOH CODE <br /> PHONE#2 <br /> CONTRACTOR I SERVICE REQUE STOR BILLING PARTY O <br /> REOtIFSTOR <br /> I �0/v GffcSi�/� <br /> BUSINESS NAME AA <br /> /ai. / FAx# <br /> MAIIJHG AOORES� ) O p�37g4 _ <br /> STATE �� ZIP 4'S <br /> CITY <br /> BILLING ACKNOWLEDGEMENT: I. me undersigned property or business owner, operator dr authored agent of same. aOmsiness that all site n this protect sped w <br /> PUauC HEeLTH SERVICES ENVIRDNMEIITAL HEV.TH OrviS10N hpuny Cha(gea as dCialed with this pmlect Or icnrvlry,wig be billed N me or my business as identified . This lone. <br /> I also mni y that I have prepared this a tion and that work to be pedom*d•x111 be done in acmance wdh all SAH JOAQUIN COu�Ortlmance Cod IandaNs,STATE and <br /> FEDERAL laws. �i�/2 DATE: Z Z <br /> APPLICANT SIGNATURE: <br /> OTHER AUTHORIZED AGENT '� title <br /> PROPERTY/BUSINESS OWNER OPERATOR MANAGER al aufhaaatlan b VOR urpu6�d <br /> pAPq,ewris naf Ce B. sr Poen prof <br /> AUTHQRIZATIQN TO RELEASE INFORMATION:When applicable.I,he owner or operator of the pro Penma <br /> y lOho at the above silo address,hereby authorize the release of <br /> any and all Results.9eolecnnipl damandlor envnonmentaVsile re resentameI matlon to the SAN JOAOUIN CCUNTY RusuC HFkLTH SERVICES EtNetGNMENTAL HEALTH DrvisloN as SOdn <br /> aS it Q available and at the same time it S provided to M or my P <br /> TE OF SERVICE REQUESTED: / / 7-Ka7T7 / ry/N� <br /> COMMENTS: 4 '5P' / (,:,-iY <br /> / y/L <br /> 4,7 �. � 1p <br /> 9 9�/- / �F'cFlVFC` <br /> ' k) .02 MGM <br /> SAW JnAODINi r)U4iNTY <br /> PUOLIC NEALYH SC•NVlf 56 <br /> ENVIRONMENTAL HEALTH DIVISIU. <br /> CONTRACTOR'S SIGNATURE: <br /> INSPECTOR'S SIGNATURE: � yl ` DATE �?j <br /> V I EMPLOYEE 4: JJ���� \ T <br /> APPROVED 67: U <br /> DATE: <br /> E APLOTEE#+: <br /> ASSIGNED TO: ) 1 <br /> i n n 'sERV10E CODE: ��✓�..� J P 1 E. <br /> I Date Service Completed I f already completed): '7 Lv I Payment Date <br /> Amount Paid <br /> = AmountReceived 9y: % <br /> Invoice# Check# <br /> aymenl Type <br /> / Ile . <br />