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+., <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST: <br /> :S2oo 33539 <br /> BILLING PARTY❑ <br /> OWNERI OPERATOR <br /> r— <br /> FAC Lrrc NAME <br /> � � L <br /> SITEADDRESS <br /> 2 Chi ss.Hxwm ou.Wn se.MNae Salus <br /> Mailing Address (if Different from Site Address) <br /> Z e-- vu <br /> Cm STATE LP <br /> <-0, <br /> PHONE 91 Ear. APN S LAND USEAPPUCATION# <br /> (4z$ $Z3 bllol <br /> PNONE#2 �• SOS DISTRICT - ' LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BLLING PARTY❑ <br /> �c:c�TT 'S.YLt�1 Sa <br /> BUSINESS NAME PHM# an. <br /> wed . 76' — to <br /> MAILING ADDRESS FAR# <br /> It 4 ,p E a 1 —_ 'A CIB <br /> Circ _ "tA G g ZIP q <br /> BILLING ACKNOWLEDGEMENT:L the undersigned property or business awner,operator or authorized agent of same.acknowledge that all site and/or project spec* <br /> PUBLIC HEALTH SERVICES ENVWCHMENTAL HEALTH DIVISION hourly charges associated wren Ina project or acdaily wit be bsled m me or my business as Identified on this,bmf <br /> I also cartfy that I have prepared this aap/pl <br /> Aication and that/ �t the <br /> Welk to be performed will be done in acrordance Wilk at SAH JCAWN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL Taws. IJZ <br /> APPLICANT SNiNAN /RE: /�f+ f DATE:kx AJ 4Ib i <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MMUGER 0 OrHERAurKRREO AGENT <br /> tAPxFJM4MIh SuacyAmr..proo/olwuxrlraeanbsignis equal Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When appfiable,1,the owner or operator of he property located at the above she address,hereby author®Che release of <br /> any and ad results,geotechnical data and/or mvimnmemallsite assessment infomution to the SIN JOAOUW COUNTY PuSUC HEALTH SERVICES EwstCNMFNTAL HEALTH DIVISION a4 soon <br /> as it is avalable and at the same time it's Provided to me army representative. <br /> TYPE OF SERVICE REGUESTw: as-r e <br /> COMMENTS: <br /> PAYM vEp <br /> I RECE . <br /> APR 21 2003 <br /> j SAN JOA�UIN S RV CE <br /> pUBL1C NTALTHEAl1H DIVISION <br /> ENVIRONMEN <br /> INSPECTOR'S SIGNATURE: CONTRACroies SIaNATuRE: <br /> APPROVEo 6Y: -Z. — O— — — d3 <br /> g DATE: <br /> Ampanizo To: YV`t EMPLOYEE#: 3 J 0 DATE: © ova, 63 <br /> Date Service Completed fif already completed): SERVICECooe - >.-Q3. PIE) a,30. <br /> Fee Amount sL(o70v Amount Paid 70-0 Payment Date p¢ 03 <br /> Payment Type Invoice# Check# 3$'7 Received By: <br /> SII <br />