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SERVICE REQUEST i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> - sR- 0 017 <br /> OWNER OPERATOR BILLING PARTY <br /> LA •F-t r')C� � � <br /> FACILITY NAME <br /> SITE ADDRESS ' 6,IR7 7 <br /> Sveel Number nirecoon Sbeel Neme Type avaaa <br /> Mailing Address (If Different from Site Add"', O Boy, <br /> CITY LLQ STATE _ IP - <br /> PHONE#1 I� Err. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE 92 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME - PHONE# Err• <br /> tt U I zt LL RSSO G <br /> MAILING ADDRESS b F <br /> �SZI -x33411 <br /> a rPop.rq or bruli QWW.oplil or radii C bi of Wew,&OW41 o.troll at Ift aiCfLlt 0*4 sAsic <br /> t,`Jl�e+taatm�bewor.errALr�uM DRWN hourly UWW assodated wh No pi or activity will be tided a na or my tikai t as asaSee m t o brim, <br /> 1 ar$aYq Tat l(rave Prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE ant <br /> FEDEFA.laws /y � <br /> APPLICANT SIGNATURE: <� 1 A.WL�DATE: 12) t��� <br /> PROPERTY/BUSINESS OWN PERATOR/MANAR OTHER AUTHORIZED AGENT <br /> IlAPvrcmr,snol r1MBBgi PnRrYl`n ..pnmfolauihorizat/on to sign is nequinE 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 ol <br /> any and all results,geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION as sooq <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: / i 12-C <br /> COMMENTS: �J <br /> PAYMEW <br /> QFcrIYeD <br /> OCT 1i2 fflok <br /> SAW uoAuuiN couNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIMON <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: (bl T" EMPLOYEE#: ( DATE: I r� <br /> r <br /> Date Service Completed (if already completed): SERVICE CODE: Q ?J 4 PIE: 2 30LI <br /> Fee Amount: Amount Paid Z3 Lk Payment Date p S <br /> Payment Type (✓\ O Invoice#'G4 634zik}I (,()I Check# Received By: <br />