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SERVICE REQUEST ..,/ <br /> Type of Business or Property FACILITY ID# <br /> 1 SERVICE REQUEST# <br /> F(aC Ir IC 5i9 fI CONAIMC llov, <br /> OWNER/OPERATOR h1 r Vo BILLING PARTY S <br /> q r QQuI Siscl�o-fber9er <br /> FACrury NAME (� n h 9 T— <br /> SITEADDRESS I y /1 k/. A d A r 'r" R4 . <br /> 3 I 3 3 Street Number Direction ,i Street Nam. ype Surte% <br /> Mailing Address (If Different from Site Address) <br /> P. 0. Box 15570 <br /> CITY 5TQcK �01n GAA zip g7r20,Z <br /> PHONE#1 LAND USE APPLICATION# <br /> (k`) 9' 3 1 - 05 ,S O * APN# <br /> PHONE#2 Er. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY U <br /> K �- ��t� M � K � bb�v, <br /> BUSINESS NAME t y. PHONE# Fxr. <br /> hdvYlolc :d (j.o �vlveronm•n7d1 fTvfc }0 1467 -(oo6 <br /> MAILING ADDRESS 14DO 5 N. tMr 50h (;Oq) 467 — 1115 <br /> CITY 570 C 9100 STATE GA zip q5).0 <br /> BILLING ACKNOWLEDGEMENT: I, the Undersigned property or business owner,operator or authorized agent of same, acknowledge drat all site andior project spacific <br /> PUBuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I 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 /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: -;-,3� <br /> PROPERTY/BUSINESS OWNER ❑ OPERAT R MANAGER OTHER AUTHORIZED AGENT <br /> IfAPPLcmirrisnotilielfPmly Prnefefaufhnrrsadnn to sign iarwryeed Title <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 ail results,geotechnical data andtor environmentalisite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH MvisiON 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: <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: 0 V E."PLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: n DATE: <br /> Date Service Completed (if already completed): t•� SERVICE CODE: P 1 E: 07.3?31/9 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />