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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR ' BILLING PARTY <br /> FACILITY NAME <br /> SITE ADDRESS1 1(.� l u- NM <br /> Sbwr Nrrmev WrMlen SeMrNnw T. SuiNi <br /> Mailing Address (if Different from Site Address) <br /> CITY STATE ZIP <br /> L <br /> PHONE#1 E:r. APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 aT BOIS DISTRICT LOCATION CODE.. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PWYK <br /> BUSINESS NAME PHONE# <br /> SSU IN I X35- ? <br /> MAILING ADDRESS FAX# <br /> U 5 s >v Co <br /> CRY V STATE ZIP S 5 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business ower,operator or authorized agent of same, acknowledge that as site ardor project specific <br /> PUBuc HEALTH SERVICES EwRONMENTAL HEALTH ONtsION houdy 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 have prepared this application and that the work to be performed will be done in accordance with as SAN JOAC)UIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL IaWS. <br /> APPLIcABT SIGNATURE: �A 24A' � -- DAM <br /> PROPERTY I BUSINESS OWNER IID OPERATOR/NWLIR OTHER AUTHORIZED AGENT vrG tANNP, 1Z <br /> IIAFPLR'A isMfs Pwnv Proofofaomeraadon to sten a reposed rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property looted at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data an Uor emironmentaVsite assessment information to the SAN JOAQUIN COUNTY PUauC HEALTH SERvIcEs EwRONABffAL HEALTH DIVISION as soon <br /> as It h available and at the same time it is provided to me or my represemetive. <br /> TYPE OF$ QUESTED: <br /> COMM nn <br /> KEmo� �s-►`rnc���i�� <br /> FEB 2 5 1999 <br /> PUB N JOAQU7N COU <br /> ENVIRON C H H ETRV S <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: p <br /> APPROVED BY: EMPLOYE`#: a 9 DATE: <br /> ASSIGNED TO: EMPLOYEE#: l0 3 DATE <br /> Date Service Completed (if already completed): 1 SEmntECQDE: c) 3L4 I PIE: 3 0 <br /> Fee Amount '� Amount Paid L Payment Date a�9 <br /> Payment Type Invoice# Check# a aa,7) Received By: <br />