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SERVICE REQUEST <br /> Type of Business or PrOPtrty FACILITY 10# SERVICE REQUEST <br /> r E0-CIA cP 4 5PC/-) 2-110-2- <br /> OWNER OPERATOR BLLILIG PARTY❑ <br /> HOMSEnlI --T Rl N KLF- <br /> FACILfIY NAME <br /> SrrFADDRESS D sc I KA S5 C?/V a(�+ <br /> sminwna. lar,m� sa..l n.m. TYo. Swsl <br /> Mailing Address (If 0i erent from Site Address) <br /> crrY k.A STATE61A 3 7C, <br /> PHONE#1 W. APN# LANDUsEAPPucA=N# <br /> ( ) 1236U3 l /U O <br /> PHOME#2 aT BOS DLSTwcT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR B"M PARTY <br /> BUSINESS NAPE PHONE# CII. <br /> ALLY ( / E c C6 : ida 3 <br /> MAILING ADDRE5s .� FAX# <br /> Po. .7 c s "v7 <br /> CaY .� STATE 0A LP Lys 3 S <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business Omar,operator or authoruad agent of same, aaramtedgo Gat Jail sde ander project specific <br /> PUBLIC HEALTH SERVICES ENY U4AE.IfTAL HEALTH ONISICN hOudf dlatge.,associated wah Nis PojeCl or aC tIt Will be Ned to me or my b"iness as klmaed M Glc:fort <br /> I also curay that I have prepared Nis �(ypbon and a^ N ml <br /> be perfoed wit bo done A aaardarKa wiel all SAKI JOAGun CaRm Ordwence Codon.Stan <br /> FEDERlaws, Mards,STATE <br /> AL and <br /> APPLXA.WSIGMATURE: M1E <br /> PROPERTY/BusewSs OWNER ❑ OPLRATCR/MANAGER ❑ 01HERWmORUED AGENT <br /> YAPP[X O,aV.Br11.'?..?!'!r+aafa1audadU0On rosipals Wj"d ill/e <br /> AUTHORIZATION TO RELEASE INFORMATION:Whm aPpirabl%L Ga amleror operator of Gla Property 100MOd at Gla abw a.its addnas.hereby auMorLm Ne rohase of <br /> anY and aa results,gat UM 3l data t Lror BrViONf)mlaGSipe asseasrrenl inforlLaOM 10 Ne SAN JOAOJN COUNTY RELIC HEALTH SERVICES E MWMENTAL HE1L:11 DN=N az soon <br /> az it R available antl at the same thne itis provided b me or my represenubov <br /> TYPE OF S ERv)cE REQUESTED: <br /> SI 2XA SU S�fiZF/1c� �ofL/%?l+Y/.i✓A u7ry 4EPOeieq F e5 <br /> CouwExrs: <br /> PAYMENT <br /> RECEIVE' <br /> NIG 142f' <br /> SAN JL)AOUIN <br /> PUBLIC HEALTH SEPV!C <br /> ENVIRONMENTAL HFAUti "- <br /> a <br /> INSPECTOR'S SIGNATURE: COHTAACTOR'S SIGNATURE: <br /> APPROYED BY: EswLOY::Q; / DATE: <br /> As-s GNED TO: �--. <br /> I'1 S t fl EsmnoYEE#-. -73 � ) DATE: <br /> Date Service Completed{rf already completed): Stamm CODE 3� S 'P/Et <br /> _2 <br /> Fee Amount et Amount Paid Payment Qate <br /> Payment Type Invoice Al Check S Received 1 1 <br /> '�IwrGn m n <br />