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SERVICE REQUEST "Jj <br /> Type of Business or Property - FACILITY ID# SERV E REQUEST# <br /> Q �� ` 0023 �s3 <br /> OWNER IkERATOR BILLING P <br /> FACILITY <br /> SITE ADDRESS �L� \rbx CSL �, .`��Q <br /> �J Ty", <br /> 4obe <br /> Mailing Address DiH nt from Site Address) <br /> Cm Stn ZIv <br /> PHONE#1 ur APN# LANG USE APPLICATION# <br /> S3n0 <br /> PHONE#2 Hr. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR BILLING PARTY❑ <br /> e <br /> BUSINESS NAME # �� Y�' w` <br /> MAILING AOD t 1 /N � /J6(xo <br /> �/(��(J�IJ <br /> CITY T �� y+ STATE ZIP ( _^ / 1 <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, admoMedge that addssite/anchor protea speafic <br /> PUBLIC HEALTH SERVICES EW RONMENTAL HEALTH ONM*N hourly charges associated with chis project er acwily will be billed to me or my business as Idendfied ml this bon. <br /> I also certify that I have prepared th' limbo and toot the work to be performed wd be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL LM. ,r/{/ 7 <br /> APPLICANT SIGNATURE: DATE: / �+/ <br /> PROPERTY I BUSINESS ER ❑ ORI MANAGER OTTER Alm1oRIIFD AGENT ❑ ` If <br /> NAPPUrWis MIM P Proorursuerortardw(osranarsouxed rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1,the owner or operator of the property bated at the above site address,hereby author®the release of <br /> any and all mutts,geotechnical data amitof envifonmentallsite assessment information to he SAN JOAWN COUNTY PUBLIC HEALTH SERVICES EWRON,ENTAL HEALTH DIVI"as soon <br /> as I u available and at the same time it R provided to ra or my mpresentaCve. <br /> TYPE OF SERVICE REQUESTEOf _ u ,'�e` - / ( <br /> COMMENTS: (,� I <br /> RECEIVED <br /> APR 12 2000 <br /> SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE CONTRACTORS SIGNATURE: <br /> APPROVED BY: EMPLOY--#: 0 t)Z% DATE: <br /> ASSIGNED TO: , )- EMPLOY--#: U L j I DATE <br /> Date Service Completed (H already completed): SERWLECOOE: 3 PIE: <br /> Fee Amount: 7� /� Amount Paid Payment Date <br /> Payment Type VInvoice# Check# ( n Received Br. <br /> I W �'V� <br />