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r qq,, <br /> • SERVICE REQUEST i <br /> Type of Business or Property FACILITY ID <br /> SERVICE,REQUEST I <br /> I-DS%19V\ 4 <br /> OWNER/OPERATOR 81111Nc pA}Zn� <br /> VV4\& Sca <br /> FAcwy NAME o <br /> C 0 <br /> SITE ADDRESS <br /> O knbr' Drncrion (� S4wt Mme __ Tyw Surly l <br /> Mailing Address (if Different from Site Address) <br /> CITY L ZIP <br /> aoE#' ' S E". APN#0 q!)- tAHoUSEAPPIJr-AT>o <br /> PHONE fl2 Dcr <br /> BOS Dtsrluct LOCATTOM CODE- <br /> CONTRACTOR I <br /> ooE-CONTRACTORI SERVICE REQUESTOR <br /> ReauESfoR BIt.LW(;PARTY D <br /> BustNess NnirE <br /> _ 4 P #� Cao PO vl2 <br /> MAtuNGADDRESSIE . " <br /> t F`Y 3 b <br /> IT:7 60 �# <br /> CITY l' STATE ZIPCA <br /> a <br /> BILLING ACKNOWLEDG? MENT: I, the undersigned property or business owner,opaator or authorized agent of same, admaMedgo that all site and/or project specific <br /> Pusuc HEALTH SERvrCEs EmiRct mEHTAL HEALTH Qms;ON hourly charges associated with this projector advity will be Wed W me or my business as identified on this comm. <br /> I also cortity that I have prepared this appka" and Croat the rtt to pertommed w7 be done in accordance with a4 SAN JOAQ M CarrrrY Ordinorxc Codes.Standards,STATE and <br /> FEDERAL LM. <br /> APPL.IcmWSr uTURE: -t- DATE:—` <br /> PROPERTY I BUSwZSS OwNER 0 OPERATOR I MANAGER OTHER AUTHORtZED AGENT ❑ A; A-1_a[, <br /> rfAPpLr- ritrrctCme prtao(orwC�ortraaonrospehr.R,ind / rfU. <br /> AUTNOR96TION TO RELEASE INFORMATION:when appficabie,I.the owner or epwaW o(Cme property located at the above site addm3s,hereby audutre the release of <br /> any and all mutts,geoted nical data ami/or emriroamentalfsite assessment inbTnatloa b 24 SAN JOAMM COUNTY PLUX HEALTH SEttvICES&M MMAENTAL HEAL-.H OMStON as soon <br /> as it Is available and at the same Cme it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> NOV 1 5 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE d CONTRACTOR'S SIGNATURE: <br /> APPROYED.BY: ESrPLOY�Jf: <br /> DATE: <br /> G <br /> ASSIGNED T0: EYPlOYEE : <br /> 73 t-0 DATE <br /> Date Service Completed-Cif already completed): StConE: S?S -P f E:. <br /> Fee Amount: T`�ountPaid <br /> 44� Payment Date Allt lJ <br /> Qt <br /> Payment Type: Invoice# Check# <br /> ()400'+119 6 21 Received By: <br /> �� <br />