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SERVICE REQUEST <br /> Type of Business or Property FACtLffY ID# SERVICE REQUEST: <br /> Air rA SQOU3 `f2.1if <br /> OWNER l OPERATOR BILLING PARTY <br /> FACUTY NAME_ - <br /> A.l ,O t Tnc. <br /> Sim ADDRES4 <br /> /,te^ /(� / l/ <br /> r 1 5 $4 Nuala a em Ve <br /> Mailing Address (If Different from Site Address) <br /> CITY ��. STATE ZIP <br /> PHOREM APNSLAND USE APPLICATION# <br /> 190 8 1055- /go- os <br /> PNM12 ta. BOB DISTRICT LOCATION COoE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REq BmLwtt PARTY❑ <br /> JPO <br /> BU"' NAMe 0 PHONES r=. <br /> 9.1 - <br /> Muuxo 1 <br /> /n FAX <br /> Cay / S 'T3� 5 STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business ovmer,operator or authorized agent of same, acknowledge mat all site and/or project specifo- <br /> PUSOC HEALTH SERVICES EtMRCMAENTAL HEALTH DNISICN hourly charges associated wit)this project or aalvity,vine be belted to me or my business as idenlified on this form. <br /> 1 also Gently that I have prepared this appBradon and that t)e work In 5 performed will be done in accordance with as SAN JOAQUIN COUNTY Ordmanca Codes,Standards,STATE an, <br /> FEDERAL Iowa. i <br /> APPLICANT SIGNATURE: DATE: 7 [4/ <br /> PROPERTY I BUSINESS OWNER 0P;fF+21T (MANAGER ❑ OTHER AUTHORED AGENT Q <br /> r YAPPuc laottne Baotou .proorofaudluiadon to sign is rmivd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When appficable,i,the oveneror operator of the property located at the above she address,hereby authorize the release c <br /> any and as resulh,geotechnical data andfor envimnmentaYslte assessment information to the SAN JoA uN COuNrr PueuD HEALTH SERVICES EwPONMENtAl.HEALTH OIVLSICN as soot <br /> as it is available and at the same tme it is provided to me or my representative. <br /> TYPE OF SERvIcE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JUN 16 2003 <br /> PAN JOAQUIN COUNTY <br /> UBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'4 SIGNATURE: CONrRACrwes SIGNATURE: <br /> APPROVED BY: [' O` EvP1ayzE tt DAT=_• <br /> ASSIGNED TO: � p\ EMPLOYEE#: DATE: <br /> Date Service Completed fdalready completed): - SERVICECODE: o3ltc 'P I E: o` O <br /> Fee Amount QLU-7k°o Amount Paid -7 Payment Date [� 3 <br /> Payment Type Invoice Check - Racelvid By: <br />