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SE VICE REQUEST <br /> Type f usiness o r perty FACILITY ID If SERVICE REQUEST# <br /> S(� <br /> OWNER OPERAT R 1 LV BtJUNO PARTY-0 <br /> FACILITY NAME <br /> SREADORESS W <br /> l' 6 Str.M Numbs D en V " - stm'H TYV. SvX.r <br /> Mailing Address (If Different from Site Address) I <br /> DfiY ( CI C ST ZIP <br /> O'er <br /> PHONE#1 APN if LAND USE APPLICATION# <br /> (461 2,32- 7 S/q 7 <br /> PH ECT. e. �/, BOS DISTRICT I LOCATION CODE <br /> CONTRACI SERVICE REQUESTOR <br /> REQUE OR BILLING PARn. <br /> BUSINESS NAME L&,-TE <br /> 'v PHO # � En. <br /> MAILING Ss <br /> I ?. al" � 00 <br /> 7) <br /> f I <br /> CRY STATE LP �S <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 charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I haverep red this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. C� <br /> APPLICANT SIGNATUREDATE: f L.X /o/ <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT <br /> I/APPucmris not la BAI KP, ..prootofaothorindon tusiynbrequ Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operHorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or envirommentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICED ENVIRONMENTAL HEALTH DMsION as soon <br /> as it Is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECFIVEC <br /> SAN JOAU00N coUNT <br /> PUBLIC HEAJ H SERVICES <br /> ENVIRONMENTAL. HEALTH PIVI31i1\, <br /> INSPECTORS SIGNATURE: _ CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. + EMPLOYEE#: (�D� 1 DATE: <br /> ASSIGNED TO: S \C-�V ✓ lC Le fEZLoYEi#: -2�-S DATE: <br /> Date Service Completed (if already completed): SERVICECGDE: f P f E: 3� <br /> Fee Amount: _ Amount Paid / Payment Date 5 7 d <br /> Payment Type Invoice#' Chec Ftleceived By: <br />