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12/18/98 FRI 09:36 FAX 5106096304 RHL DESIGN GROUP RHL PETALMIA 2015 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 0 SERVICE REQUEST <br /> Gots STa`t IotJ 2 `-7/ <br /> OWNER 1 OPERATOR � L � 01-79 -7 (�� � �C `I7 / BLLLI�tCIAA� <br /> F�2�1LoN) ENTE2 Ruse, <br /> FACILITY NAME <br /> I F—�-Y,6C � <br /> SITE ADDRESS i 1 u <br /> `1 Clnc.Lr�-e� ��, a•a <br /> Street NUMM oireaien SO Mt NLIN TIP" Suite 3 <br /> Mailing Address (If Different from Site Address) <br /> �•C� fox 80�3D <br /> CJrr M fW-T l N EZ STATE <br /> F" ZIP 1�{5s3 <br /> PHONE f41 APN LANo USE APPLICATtOu# <br /> (715) `7-6�-7 5 IIoS - 030. 03 <br /> PHONE#2 a*. 130S DISTRICT Locum Coue. <br /> CONTRACTORI SERVICE REQUESTOR <br /> REQUESTOR BUM pAR1Y C1ST�1rE S'k->4Np>`esoi>J <br /> BUSINESS NAMEPNONE#t <br /> RNL T--)ES1CN Grow 707-`16SIbb70 <br /> MxuNG AwFiEss FAX# <br /> ( l 3 7 (J. ) 707 <br /> CITY A l U nn P. STATE C 6 ZIP / <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge Inas all site and/or project spedfic <br /> PuEuc HEALTH SERVICES ENVIRONr ENTAL HEALTH DMSICN hourly charges associa d with this project or acijvity wIU be billed to ma or my business as identified on this form. <br /> I also certify that I have prepared this app),—don and that the work to be performed wig be done in a=rdance with all SAN JOACUN COUNTY Orrfma xa Codes,Standards,STATE and <br /> FEDERAL laws. �C- -1,b <br /> APPuCANTSIGNATURE: L�zDATE: 12 `( $"�y <br /> PROPERTY/BUSINESS OWNER C OPERATOR/MANAGER ❑ QniE4 AUt}iowa AGEw col d ���G:2� <br /> U APP r.W is Mir the 88 t�Rro&of 2U&"=don to signis required Till e <br /> AUTHORIZATION TO RELEASE INEORMATICN:When applicable,1,the owner or operator of the property located at thea a site address,hereby authorim the release of <br /> any and ad msuits,geo"niral data arkUor fffarrinmentaYsite assessment information to the SAN JOAQUIN COUNTY F'U"HEALTh S ES EwRONmeffAL HEAL-, as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: '•Q✓M Q n en-f- -rG n k U S LA r-e— <br /> COMMENTS: <br /> Pi> YMEN <br /> 3 3 <br /> QDEC 21 1.998 <br /> C/s3jo <br /> - <br /> SAI,:JUAUUIN Lvvi!: <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVIS!Or: <br /> INSPECTOR'S SIGNATURE: j CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: ✓/ i EStPL^Yr.E}�: � DATE: <br /> ASSIGNED TO: EmPLOYEE#. �I DATE: <br /> t7 <br /> Date Service Completed (if already completed): SERVICE CODE: - - � P f E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice t# c Check# Received By: <br /> Y YP S S 9 Z c� <br />