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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST <br /> OWNER I OPERATOR BILLING PARS❑ <br /> FAcIUTY NAME a2� 05 ED <br /> SITE ADDRESS ld , <br /> � o2 4,n�..n.r oo.mm A �� a/LT m.. rmd <br /> Mailing Address (If Different from Site Address) <br /> CITY 5-r& <br /> T N E � <br /> &�-�%C' / STATE <br /> 0 � <br /> PHOME91 Lu. APNA I Ao USEAPPUr-ATaN9 <br /> VAP) L7 - 44nrt) <br /> PHONE 92 rs. BOS DISTRICT I.ocAwN CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQU OR BILLING PARTY❑ <br /> BUSINFS`N�uE PHONE It �T• <br /> �e,s TVLc_ 204 23 0518 <br /> fMWNG ADDRESS FAX» <br /> lea Fuca PI, W [20 234 - osact <br /> CITY L Gf STATE C A, LP -I <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business awner,operator or authorized agent of same. adTaxi dge Nat all site andfor pmjed speak <br /> PUBUC HE LTH SERVICES ENVIRCNAFMAL HEALTH DIvis"hourtf dtarges assoaated wdh Ma pmject or actey will be bled to me or my business as)dwtified on Otis form <br /> lzteo certify tnat I love pmpared Nis aPV�tion and Ne work m pedo wa W done in auardarwo wiN aG Cotxrlr Ortlinenca Codes.Standards,SYA1E and <br /> laws. <br /> PL1UlrT SrGruTURF: <br /> PROP ERTYIBUSWESSOWNER ❑ C4EAATORf ❑ 1h747T A1f11Kai7g0AGERT ❑-/F <br /> aAArsrr 4nc(llr BerMGPAnlY Proddrrfh don Nslpohneo:ed TRIO <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.L the awrTer or operator at the property located at the above site address.hereby auttnrlbe The re"m of <br /> any and all resuits,geoteamical data an:YO(Briviarinterltaysdo aaat [itt anat on to Ne SAN Jonwn GWNTY PtmuC HEATH SFnvCES BOmoio AL HEATH OMSP]N m son <br /> as M1 is available and at Ne same brm itis provided 0 tm or my represwulve, <br /> TYPE of SERVICE REQUESTED: l// >J` r <br /> COMMENTS: /L <br /> PAYMENT <br /> RECEIVF'3 <br /> MAR 14 2001 <br /> SAN JOAQUIN Cc)'.' <br /> PUBLIC HEALTH SF f< <br /> -^IVIRONMENTAI.';'r <br /> INSPECTOR'S SIGNATURE: CANTNAcmies SIGNATURE: <br /> APPROVED ID: %& A Elft / 'l / DATE: <br /> ASsrwDTO: j/]7 7;�Wlj, — 6 EYPLOYEE#: DATE: <br /> Date Service Completed Cif already completed): SE.RVICECODE s () 3 PIE: <br /> Fee Amount pLr Amount Pa d 1 4p ;7 `' Payment Date <br /> Payment Type a --e Invoice» Check Received By: <br />