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1, SERVICE REQUEST . vu <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> BILLING PARTY❑ <br /> OWNER OPERATOR <br /> �NJ — 1 _l <br /> FACRJTY NAME ^ — <br /> SREADORESS 5 U 1 / ��� K L L LV-CAA 1,J 1— kit L <br /> Sbti Numb. drsaaa SMtx.n. $QUAL <br /> Mailing Address (If Different from Site Address) <br /> CRY STATE ZIP <br /> L <br /> PHONE#1 <br /> est. APN# LAND USE APPLICATION# <br /> PHONE#2 BOS DISTRCr LOCATION CODE . <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR BLU Ns PARTY <br /> BUSINESS NAME PHONE <br /> MARADDRESS FAX# <br /> RIO <br /> LJU L � (� Co? rJ' Ca(lCn <br /> Cm V STATE ZIP r—\ 5 <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned Property ar business owner,operator ar authorized agent of same,admdledge that as site ardor probed speak <br /> PUBS HEALTH SERYM F.xmawenkHEALTH ONSIDNIraU11Y ChargesaappMlerlwitttb projeda ar3riy wi he!liedbr4aart Oasiem as ite�edmLei btu <br /> 1 also mr1ty that I have prepared this appkaeon and that the work to be performed wil be done in accordance with d SAN JOAOUN COUNTY OrtfRance Codes.Slandmds.STATE and <br /> FEOEPAL laws. _ <br /> ! V � c� <br /> APPLILANTSgNATURE: AA <br /> � /A ,( _ _ DAIS: � G` '—I <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR I / OnfnAuwmzm ALERT ❑V'1Z) 11• c--T �.�tnNA <br /> eAPPLc-wTNreew P dautlruhaean roalpn6regrred rule <br /> AUTHORIZATION TO RELEASE INFORMATION:When apprxable.1,the owner or operator of the Property located at the above site address,thereby auftledrn the releesa of <br /> any and aK results,geotechnical data ardor envkonmentaffle assessment Intonation b the SAN JOAOUIN COURM WBS HEALTH SERVICES E WRONMENYAL HEALTH DMSION as soon <br /> as K is available and at the same tlrrla d is pruMed to me or my Iepre3enotive. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: n <br /> K�rrto� �iJ�-�;nL�fT�rnc� <br /> PAYMEIV 1' <br /> FEB 2 5 1999 <br /> PU13 IC UFOION ALTHco <br /> ENVIRONMENTAL NCASLR/tTH j S <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: qq <br /> APPROVED BY: EMPLOYEE#: DATE: a.. �'�LS GIf� <br /> AsSIONEO TO: EMPLOYEE# O DATE ,L.{d 1 <br /> Date Service Completed (N already completed): SERVICECODE: C) 3 P./E: 023 <br /> Fee Amount ( 00 LAmount Paid 6 Payment Date a 9 <br /> Payment Type ✓ Invoice# p54 q t f�. Check 0 a as 3 Received By: <br />