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M-2-11".25005 23:47 2094683433 FIFTH FLOOR PAGE 02 <br /> 0 <br /> SAN JOAQUIN COUNTY F. ONNXNTAL HEALTH DEPARTh FLINT <br /> SERVICE REQULST <br /> Type of Bustrlm or Property FACIt. Y 109 SERVICE REQUEST# <br /> OWNER]OPERATOR <br /> r } '�` CHECK USILUNG ADDRIM)�1 <br /> FACILITY NAME A t1 v <br /> SrtF:ADDRESS <br /> Nuni6w y Na 'izip e <br /> Now or MMiNG ADDS lit Different from Site Address} <br /> m t <br /> Grly STATS zip <br /> PHpFf M 7 APN* LAND USE APPLCATM# <br /> PMM-#2 M DISTRICT LocAT,DN COM <br /> t � <br /> CONTRACTOR,#SERVICE"QUESTOR <br /> REQUE MIR CJnn <br /> �^� �CKlf BILLING ADDRB33{..�,r <br /> t3us�i ss RiAli ,25 4�(�sL cru dCj � <br /> ►� <br /> Hor ATM ` v� E� <br /> �Crrf ��_v►�'{z�ir.� 1 � sTAT2 C A z►P c� 6 <br /> BiZLIL0 A G1Q�VLEDGE14iiiN'T I,tlrc zmdersigued property or lbusigcss t+Twtter,operator or authorized.agent of same, <br /> ae wN Wge that all site an&or project specific Emi oNwj7`m HEALTEI OEPAR`TENT hourly cbmees sssooiatod with this project <br /> or activity will be billed to me or my business as identified on d1is foam. <br /> 14UO oortify that I have prepared this application and that the wok to be performed will bo done m accordance with all SAN 7oActUnv <br /> COUNTY Ordinnnes C4d;,,,Stwdards,6 ATE and FERAL laws_ <br /> APPLICANT'S SIGNATURE: l DAA: r�'c�'�—�✓ <br /> PROMTY i WMNM c WMC3 Om:RAToR i llumrm Q 0TfMtz 3a* m=w Arm°1R <br /> If APPLICANT is 0M BALM PARTP preaf ofaudw*440q to 84M is ref ibvd Titia <br /> AJD RLZATIt)N TO RMASM 'XIm applicable,L the owner or operator of the property located at the <br /> above she address, hereby atthorize the mlew of any and all results; geolbecbriiml data an&or cn,.jmnmentalisite as,-cs=ent <br /> information to the SAN JOAQUIN COUNTY E'NVI8crNMDiTAL HBALTH DEPARTWNr as soon as it is available and at the same time it is <br /> provided to rete or my representadve. <br /> TY F€tan SOMICE REQUMED: (A S-T �ice'U F f l► <br /> COMMEM. -'c�- <br /> C L_i ur '�� EltevitfrFFd; &3 Z/ ©arE 2 2 fc� <br /> Aa mmrTo: C/} J 6� EWL*Ymk e3fj DATE: Z -2 GS <br /> Date SerVice Completed tit already coal): SM=CME: g p 1 F- <br /> Eee Artmnt: 7 ` ' Arnount Paid Payment Date'757 �--�� <br /> Payment Type invoice# Check B Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REV!$ED 11117/2403 <br />