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SERVICE REQUEST <br />Type of Business or PropertyFACILITY <br />BUSINESS NAME-----' � � � <br />r/ <br />ID # <br />1 000 <br />SERVICE REQUEST # <br />S910,0 333 �7 <br />OWNER I OPERATOR <br />S <br />Cm �� STATE ZIP /? <br />BILLING PARTY( <br />FACILITY NAME- <br />0,- <br />SITEAoORESSI <br />G <br />/✓ Street Nwnbw <br />OGection <br />�SDwt Narm <br />Ty" <br />Suits x <br />rom Site Address) <br />Mailing Address (if Diffen- <br />,, <br />pUBIL NG <br />HEN�SH DIVISION <br />CIT,Yn <br />1 <br />EW0)NMENTNI <br />STATV/,p ZIP 4� C9 2 <br />`/ <br />PHONE#1 EV. <br />AP# <br />N <br />LAND USE APPLICATION # <br />PHONE is <br />DATE: <br />BOS DISTRICT <br />ASSIGNED TO: <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , BILLING PARTY 6 <br />BUSINESS NAME-----' � � � <br />r/ <br />P�/�p #CG(L/7 <br />MAILING ADDRESS (� / 1� " <br />FAX# <br />o �D <br />Cm �� STATE ZIP /? <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this Nood or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with ad SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: `' `� C il.��Crv' `'� r DATE:�v - <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER OTHER AuiHORIzED AGENT ❑ <br />H APFUC.wr is not ft AVtry proof of audwintlon to sign is required ri t 1 e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of <br />any and all results, geotechnical data aNJlor environmentaUsite assessment information to the SAN JOAQUIN CouNTY Pueuc HEALTH SERVICES ENVIRONMENTAL HEALTH ON sioN 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: l c R4r 0 1 <br />COMMENTS: <br />PAY <br />9ECE D <br />APR - 4 2003 <br />H S RaES <br />pUBIL NG <br />HEN�SH DIVISION <br />EW0)NMENTNI <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: (j� , Q J �}� <br />E.VPLCY=#: -- j -b � L <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE # 7( <br />, <br />DATE: <br />y �1 3 <br />Date Service Completed (if already completed): <br />SERVICECODE: <br />1q y <br />PIE:. <br />Fee Amount: 2 <br />Amount Paid (o� Payment Date c) <br />Payment Type ✓ <br />Invoice # <br />Check # —)4(,t 1,3 C <br />Received By: <br />