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SERVICE REQUEST <br /> Type of Business or Property FACILITY 10 9 SERVICE REQUEST S <br /> OWNER I OPERATOR // BLLLWG PARTY <br /> ls� <br /> FACILTTY NAME <br /> $RE ADDRESS <br /> s.'. oC— L t <br /> Mailing Address (If Different from Site Address) ` <br /> CrT7 STATE Zip <br /> PHONEKI APN4 LAND USE APPLICATION <br /> PHONE C2 Exr. BOS Dwpj= LOCATION CODE <br /> V <br /> CONTRACTOR I SERVICE REOUESTOR <br /> REQUESTOR BuiHo PARTY❑ <br /> 4 V <br /> BUSINESS NAPE PHONE R Da. <br /> tort ZZ-• - U8 oL, <br /> MAILING AWREsS FA%C <br /> C" STATE A. ZIP <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner,operator or authorved agent of same, admowkdgo Nat all site and/or P(ojoa speck <br /> Pueuc HEALTH SERVICES EwRCT &HE-LT N OIv"taury dwgm ass tcd wdh The,projM or xAnty vM be bitied to me()Tiny business as idwaried on Nis form <br /> I also OHWY that I Rave prepared Nis application and UW the worn to be perh:nned will be done n 2o9Narke with all SAN JQAam COUNTY Ordlne Codas.Standards,STATE and <br /> FEDEAAL laws. <br /> APPLICANT SIGNATU ( 1j <br /> _ DATE I t;fly <br /> PROPERTY I BuSwESs OWNER OPERATOR/MANAGER ❑ OniHAUngRUEDACENT ❑ <br /> Y QaLNCPAarr.Pruddw1odr.0w b4ipo6 r."vd Tin# <br /> AUTHORIZATION TO RELEASE INFORMATION:when appfrable•L the pwneror operator at the property located W the above site address.hereby audlortm the rebase of <br /> any and all msur6,9eotechn cal dam aloes erTvironrnentaVsao assmsrnent intonneOon lO the SAN JGAam Coutts Puauc HEALTH SERVKEs ENve cHmENTAL HEALTH ONLSVJN y soon <br /> as A Ls avadable and at Ne same tlme A is provided b me ormyrs) c <br /> xenlatw <br /> xTED . ,t/ <br /> TYPE OF SERvE REQUESTED: Sod St-11tckw I}I � ( NUJ <br /> COMMENTS: <br /> 1 '7"/'o�v„z <br /> ` �JAYMEIN 1 <br /> RECEIVES <br /> 1111ry 3 1 goo? <br /> SAN JOAQUIN COUNTr <br /> wry RI-NM HEALTH SERVICEFINTAI '1 <br /> INSPECTOR'S SIG RE CONTRACTOR'S SIGNATURE: <br /> APPROYED BT: Eumzy::P. "l "��'"L DATE: <br /> ASSIGNEOTO: FJIPLOTEELr: V I DATE: <br /> Date Service Completed{rf alrea mpleted): SERVICE CODE: 'P I E- <br /> Fee Amount: + —1 Amount Paid Payment Date <br /> Payment 7ype I Invoice 9 CheckC Received By: <br />