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aSERVICE REQUEST . 6 ' <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> GG s v 6 c P- Q les cow / -7 S6Z aU Z90 <br /> OWNER OPERATOR / o T E3 <br /> v-o S BILLING PARTY❑ <br /> FACILITY NAME / >--0.t. ,✓ I �Q �. � h <br /> SREADORESS 15 D D _S. 4 a- V— I G V— /C CR- <br /> / Str,rt Xumb�r DkKd.n StrM Nma Tyne soft,/ <br /> Mailing Address (If Different from Site Address) <br /> Al <br /> Cr / S` wuLPCITY ��-It- r I ST�?A zip S 3 D <br /> PHONE#1 APN# - LAND USE APPLICATION# <br /> (X'() u�2 - r/ hySG <br /> PHONE#2 Ezr. BOS.DIsTRrr LOCATION CODE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR ) <br /> BILLING PARTY <br /> BUSINESS NAME -� PHONE# En. <br /> .{- -y <br /> MAILING ADDRESS Fax# <br /> mo <br /> Oftt _—e STATE ZIP Seo <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 /> PueuC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed to me or my business as identified on thla form. <br /> I also certify that I have prepared this appli don and that the work to be performed will be done in accordance with all SAN JoAWIN CoLINTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: O —.z 2— C7 J' <br /> PROPERTY/BUSINESS OWNER ❑ OP T !MANAGER A< OTHERAUTHORIZED AGENT ❑ <br /> lfl PA wris nor ft BXIMPamv.prop/olauthodrallen resign rsrequhvd Title <br /> AUTHORIZATION TO R SE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geol nical data and/or environmentat/sile assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. rp A EMPLOYEE#: DATE: <br /> ASSIGNED TO: — EMPLOYEE 9: `; DATE: <br /> Date Service Completed (if already completed): ✓ SERVICE CODE: yg P 1 E. <br /> Fee Amount: r� Amount Paid UP- - Payment Date 3 c 1 <br /> Payment Type Invoice#' Check# Received By: ' <br />