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SERVICE REQUEST <br /> Type of Business or Property FACMID SERVICEUEST0�' <br /> OWNER OPERATOR C. <br /> —� BILLING PARTY <br /> �L�l ��fa C��C�OrvS <br /> FACILITY ME <br /> SITE 03 ADDRESX �. �� <br /> `` Street NumOm oinctlan StrM Nama Type Sunei <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE zip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 SOS DISTRICT LOCATN)N CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR /BIILLIN��G""PARTY C <br /> BUSINESS NAME P # / I/-�'A/I ✓' 1+ 0. <br /> MAILING ADDRESS CJ ,n , // FAX# �1 l <br /> CIrY STATE ZIP <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 ENVIRONMENTAL HEALTH DIVISION hourly changes associated with this projector activity will be billed tome or my business as identified on this form. <br /> I also cenify that I have prepared this application.and that the work to be performed will be done in accordance with all SAN JOAQUIN COLNrf Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER Cl OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IIAPPu T1Sn0tthe QU,NGPARTY.Praofof=dMd:adon to sign is nquind Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time lt is provided to me��'oor�r my representative. <br /> TYPE OF SERVICE REQUESTED:11". U,/)/)o_ /) <br /> COMMENTS: V V t(J �/!A�_ <br /> DEC 17 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOf, <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> iv'F'nv'V'cG GT: EMPLOYEE#: DATE: <br /> ASSIGNED TO: '� r _ EMPLOYEE#: DATE: /a �I <br /> Date Service Completed (if already completedi. SERVN:ECODE: p PIE: <br /> Fee Amount: L f 8'� Amount Paid b 0' Payment Date <br /> Payment Type - Invoice# Check If 0 &(o 7 Received By: <br /> r <br />