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441' <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY 11) <br />SERVICE REQUEST K <br />// <br />APPROVED BY: <br />BILUNG PARTY C <br />FAc NAME f` <br />,, <br />,'.t , <br />SRE Aomss <br />EMPLOYEE <br />DATE: <br />Date Service Completed (if already completed: <br />IS / _tw sCNtNurrblr <br />D4eeeen <br />scarnsee <br />Type <br />Suns <br />Mailing Address (If Different from Sb Address) <br />a <br />CrtY STATE ZIP <br />PHONE 94 ECT- <br />APN # <br />LAND USE APPUCATION # <br />PHONE t* QT <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR SERVICE REQUESTOR <br />REQUESTER <br />BLLtNG PARTY ❑ <br />BUSINESS NAMEt i - ( _ _nccv{ r V 1 ►�1 iJ��I I/���i I I i*7Q/ d( -6-1Z? / 6 / I <br />MA0.1NG ADDRESS`1qI. Y O . /-� t sto .Y-.IPJ�� I ` 6FAX � 2.0&3gqr � 251 <br />CRY fr �1 ��� t! � _•` STATE LP J 1 <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 ENVIRCNIENTAL HEALTH DN1S1014 hourly crarges associated with this projector activity will be billed to me or my business as identified on this Cann. <br />I also certify that I have prepared this appficatlon and that the work to be perfomred will be done in accordance with all SAN JOAOUIN COUNPr Oetnarce Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: DATE:�� <br />PROPER rY/$USIRESSCPERATQRIKANAGER cl Ot�AunxAtMDAGENT ❑ <br />V APRT-wr Ll rat ft gym P iArY. proof of mfbonmdoe to sign is mWind Title <br />- <br />AUTHORIZO RELEAtTNORCSN: When applicable, L the owner or operatcrof the property located at the above site address, hereby authorize the release of <br />any and all results, geetechn pt data and/or em rort en2l/site assessment information to the SAN JOAO(m COUNTY PUBLIC HEALTH SERVICES EWRONMENTAL HEALTH OrviwN as soon <br />as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVrCE REQUESTED: <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVED BY: <br />Empt �`,7.. <br />DATE' <br />ASSIGNED TO: <br />EMPLOYEE <br />DATE: <br />Date Service Completed (if already completed: <br />SERVCE CODE: <br />-P f E: <br />Fee Amount <br />Amount Paid Payment Date <br />Payment Type <br />Invoke # <br />Check # <br />Received By: <br />