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GA.0000szq?q <br /> SERVICE REQUEST tSMME <br /> Type of Business or Property FACILITY ID rR DOG 3cjR� REQUM JO <br /> BILLING P <br /> OMMERIQPERATOR <br /> 1'\Y /LiSI'✓\ IE:TflL t SICz�U <br /> FACLm N <br /> SITE ADDRESS 11` !I mm� w�� <br /> 3sla sub.xw a. Ianmon /Y � +�w�. Trw subs <br /> Mailing Add (If 99If erent from Site Address) <br /> L� PoarLlr� u <br /> Crrr ST ZIP . <br /> Lt'nA <br /> E[r. APN# LAND USEAPPLICATION <br /> PHONE#t # <br /> (78 070. 5306 <br /> PHONE#2 SOS DISTRICT Lowsom CODE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR BaLBIG PARTY C1 101 <br /> BUSINESS NAME 17- <br /> / <br /> MAILING ADORES <br /> V % 21) _ /a F^� <br /> CITY (Jj /\ (�C STATE/^// ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authomsd agent of same, acknowledge duft ad site7andim project sped& <br /> Puauc HEALTH SERVICES EWRONUH+TAL HEALTH ONISION hourly barges associated wdh Ibis projector achtY w li be billedto me or my business as idenef{8d on this tomb. <br /> I also certify that I have prep this tion and tat the rk to be performed will be done in accordance with all SAN J0AOt1N COUNTY Onfinance Codes.StandardS,STATE and <br /> FEDERAL taws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWN ❑ !MANAGER Lam' OTHER AUTHoww AGEMT ❑ LlYL_. <br /> CAmtlGvrrd"MBr!boPwm POMfdardrrarhadenmsignisrbeueed 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 an Vor emrkonment3USae assessment information to the SAN JoAauN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the Same time it is provided to Ire or my repreSeradve. <br /> TYPE OF SERVICE REQUESTED: / J.. <br /> COMMENTS: 1 <br /> PAYMMN II <br /> RECEIVED <br /> APR 122000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: 1 x kA EMPLOYEE#: �'�' , DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ) 'P I E:.2 . <br /> Fee Amount: - 00 Amount Paid Payment Date <br /> Payment Type Invoice# Check# - Received By: <br />