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SERVICE REQUEST <br />rACILI TV to ,RECORD 10 , <br />rAC III TY NAME __-,IJ~_'/J_t_fT_ft/_l._O__:-r....;...I"l...;~_~__.J'+_ <br />SITE ADDRESS _--=:!¥::..:(7~roL.:=--_~~_.L!::..~O:..::(/:Lr.:...:/£=-=--_c.r.!-l....------ <br />CITY _---=s-'---r_~_e-_tf_/V__•.•_CA ZIP <br />O\INFR/OPERATOR BILLING PARTY I VI N <br />DBA &~,,_,_c..-c..._=PHeJlE "(,_ <br />IIOORESS /lCJ /-":/??RY~~U~?J-<-rJ'o <br />CITY ,rn.c-fc Tl---J STATE C ~ <br />r=APN"I[~and Use Application"eo::===-==-==-==-===II I I I IL!t (-~JO rOC::,.=V f'q'-f .-.3 80S Dllt Location Code <br />f:ONTRIICT(Jlnnd/or ?1'I4-/L'1 -t-a.:lit:....I ;e=>=\I <br />"FRV J CE REQUESTOR -'&~~==-_=_:O'___r "'_C-_tr_f/t._l--_O___B ILUNG PARTY Y I '--!c! <br />PHeJlE "(~,~I Z -::r 4:5-7' <br />FAX'(__~_~"<-.~.lev-<- <br />PHON!ilZ ()_ <br />ZIP ~.r2"t!/----~----- <br />~1~DBA ~p~_ <br />Mil'LI NG ADDRESS tri--"p_,_"'"S---""_ <br />CITY _STATE __~_ZIP _ <br />RILLING ACKNOYlEDGEHENT:I,the underllgned owner,operator or agent of same,acknowledge .t _11 sft.andlor project specific <br />PHS/END hourly charges associated with thll facility or activity will be billed to tha party rdfritffl~••he IILLING PARTY on <br />Page'of this form. <br />I also certify that I have prepared thll application and that the work to be perfpr v,JOAQUIN CWNTY Ordinance Codes and Standards,St.te and Federal laws. <br />~'APPLICANT'S SIGNATURE :~& <br />v1ll "-dqne In K~dance with all SAN.. <br />"'Iv. <br />TI tle:__---',,;.<..:...,.<7:;....:~:....If.:......:...7"_~/G__:;;..__.:v.~~_.:~_~_-D.te:__---l~'----_'7-..:.r_-_9~y~_ <br />AUTHORIZATION TO RELEASE INFOR~TlON:In addition to the .bove,when applicable,I,the owner,operator or agent of lame,of <br />the property located at the above lIte address hereby authorize the release of any and all resultl,geotechnical data and/or <br />envlronmental/slte assessment Infon.atlon to SAN J~OUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a.loon a. <br />It I~available and at the same time It II provided to me or my representatIve. <br />Service Cadit ex,J..Nature of Service R~lt:'{l ~5Ct (7&-lio~ <br />n-L('~r/A'I';ignedto -B:T?b Le d,c?vL Q Z E""loyee ,0 r :»(..,Date __I 1 _ <br />Date Service C~leted __1 1 _Further Action Required:Y I N PROGRAM elEMENT -'-...:::::~~__ <br />Receipt'>Recvd ByAmuntP.ldFeeAmount Date of Payment Check'Payment Type <br />B,==:-;;=/:-;;;=I;;;=-==EJ=SU=P=V=:!==:-;;=I;;;;;;=_=I;=_=_=:!q=A=CC=T~~~=Lf=I=;Jb==1=Cf=Z'===I,=UN=IT=C=LK::::::::!==~-;;I=_=_=_=/~~~I