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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID rl SERVICE REQUEST 0 <br /> OWNER I OPERATOR CNec+r N 13 <br /> �1 A rs'r k C�# uN+h�z S� X tf Wit.. ��a ��� <br /> Srrr AtDaam s qL oo PJ I L41 pA A r-.E-C a 9 3'3 <br /> flow or NUKm AmEss I1f Different from ant Addreesj <br /> PQ 3 2— AWWWWo <br /> CITY STATE ZIP <br /> A rirfc C-R S lF <br /> PWW#I APN U*0 We APAL"MN D <br /> (4 ) 8?K- 32,oQ - ala - 13c� <br /> P"M n eOs oraTacT Le"irar Coca <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RFC"EsTott <br /> r�11�.(� �>,J �1l r'�;F�t,►.�(1 �MA tz�ki,,l Sw ti FT� Crredt u&auto ADt»u<ss <br /> Sumwn NAME p * ear. <br /> m C, tea til l rJ(1 2--q ''(wz- <br /> Hams or UmNe ADDREw FAX* <br /> *7-q 'Q� o 2r" ( •,t) 2-' 9- <br /> cm MAWTECA STAta CrF Z", qS 33to <br /> BILLING AGk2LQVYLEQI;fJIiE[ 1. the undersigned property or business owner, operator or authorized agent of samt, <br /> ecknowtedpe that an site aWor project spetifiC EN m0HMMTAt Hem,Tm DEPARtmEw hourly charges associated with lho project or <br /> activtiy will be billed to me or my business as Identified on this form. <br /> I also certify that I have prepared this application aril that the worth to be performed will be dorm in accordance with all SAN JeAouN <br /> CcxrNTY t?re s=s Codav,Standards,STATH and FEDERAL lows. <br /> APPLICANTS SIGNATURE: DATE: <br /> Pnwrff"I Busmas owmax❑ OPROATOR I MANAOQR 0 0THER&1rNoRQED AoENT de wi L. E►`%N-4 E C�— <br /> If Anw..rr"wr is nor ft Mkm proof of authortsadon to,*n Is roqufred ritl e <br /> ANMRIZATION TO RELEASE WgRM1►TION: when applicabio. I. rho owner or operator of the property localed at the above <br /> site address.hereby authorize the relseve of any and all results,geot©chrikel data"or envlronrnentoi/Bite,esseument tion <br /> io the Sow JoAoue+CouNTY F.wimONWNTAt HF1 ni Dar+Aat EMT 85 soon as n is available and at the same lime itis PnDv <br /> my rapcesentative. <br /> TYPE or SIRv1ct:REour:sm: <br /> jt�Cawerwrs: j 4/ <br /> ACM <br /> vraD 8x: EnmtDYee : DATE: . . <br /> A=KMD TO: Emot.0ya t DATE: <br /> Data Service Completed (d already 0046010: SIM Cane: f@• <br /> Fee Amount: Amount . OD I Payment Do* � <br /> Payment'ryp I "Vg I I Invoice SJChock 1t �Me/ �R. Ry: <br /> EHD 4e-02-025 9R FORM(Gakien Rod) <br /> 07MV0 <br />