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SERVICE REQUEST <br />Property <br />Type of Business or Prope <br />..� S� �l0 Sin t <br />�- U-1 <br />FAC:LLII'TY (IDD�� <br />r/ i� <br />SERVV�IC`El REQUEST t <br />BILLING PARTY <br />OWNER! OPERATOR <br />,u� <br />S0\yo <br />SP���N, µ �pRN1pMS10N <br />Ftp P�SN`Ih�t�iPL <br />FACILm NgME <br />APPROVED BY: -- C GI <br />SITE ADDRESS ' SS3 <br />StraK Numb.r <br />Oir,cnon <br />$tra.t Nan,. <br />ASSIGNED TO: L� �i EMPLOYE -r#: 1. <br />i I <br />Typ. <br />suit.! I <br />SERVICE CODE: <br />P l E: 3C)e <br />Fee Amount c2�! G e I Amount Paid - v <br />Mailing Address (If Different from Site Address) <br />Payment Type i / Invoice # <br />Check # �� <br />Cn <br />STATE ZIP <br />PHONE #1 ET. <br />I APN# <br />LAND USE APPLICATION# <br />( )SCS — lJ%�{ <br />PHONE #2 <br />I ( <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR BIWNGPARTY <br />PHONE <br />^BUSINESS NAME , } r <br />SC (\l h C ';�C��b`lS rvS u <br />MAILING ADDRESS FAx # <br />01 {~q0� d 13 — Loc) i �2) <br />j <br />CITY <br />( ( tr r ATE �� �- 7�P <br />BILLING ACKNOWLEDGEMENT: I, the undersigned propery or business owner, operator or authorized agent of same, acknowieoge that all site and/or project specirc <br />PuBL:C HEALTH SERVICEs ENVIRONMENTAL HEALTH DIVISION hourty Cnarges associated with this project or activity will be billed to me or my business as identified on this form. <br />I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />APPLICANT SIGNATURE:���A�- 1, ; Jam--. DATE: / AL L <br />PROPERTY i 5US NESS OWNER L, OPERATOR i MANAGER OTHEk AUTHORIZED AGE -11 i <br />If APaxwr a not ft BE IING Parry. Proof of 2Ud?Onz2tlon to sign is n4uomd tl 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. geotecnnlcal data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY Pusuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br />as it is availaole and at the same time it is provided to me or my represermtive. <br />TYPE OF SERVICE REQUESTED: <br />tJ� d <br />COMMENTS: <br />��—`l <br />�3 Zp03 <br />,u� <br />S0\yo <br />SP���N, µ �pRN1pMS10N <br />Ftp P�SN`Ih�t�iPL <br />INSPECTOR'S SIGNATU : CONTRACTOR'S SIGNATURE: <br />APPROVED BY: -- C GI <br />I DATE: <br />y <br />ASSIGNED TO: L� �i EMPLOYE -r#: 1. <br />i I <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P l E: 3C)e <br />Fee Amount c2�! G e I Amount Paid - v <br />I Payment Date 7 03 <br />Payment Type i / Invoice # <br />Check # �� <br />U Received By: ��� <br />