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SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID C SERVICE REQUEST# <br /> Off ':�?o S�s <br /> OWNER/OPERATOR T� ( V3 rv-\- BILLING PARTY,3 <br /> FACILITY NAME <br /> SrrEADDa u ,F�e✓l� <br /> SVenNamUr �cEon �-C�F " �--aa.w Nana it � Swur <br /> Mailing Address (It Different from Site Address) <br /> Cftt �(— .. STATE.r, ZIP <br /> PNON Xt APN ft LAND USE APPLICATION$ <br /> PNONE R2 Ea. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQIIESTOR , BILLING PARTY <br /> fK <br /> BUSINESS NAME P ONE f �• <br /> 02 <br /> MAILING ADDRESS I Q F c 8 <br /> CITY 0a UrAa' STATE LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authored agent of same, acknowledge that ail site and/or project specific <br /> PUSLL HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges aSSOGaled with this project or acJvity,will be billed to me or my business as Identified on this torn. <br /> I also candy that I have prepared this appliadon and that the work to be performed will be done in acrdance with all SAN JOAQUIN COUNTY Ordinance Cedes.Slandards.STATE and <br /> \(�1FEDERALlaws. '' - <br /> J'APPLICANT SIGNATURE: �n I \'J 1 tit (( DATE: .L_f <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> CAwr TfSr0ftle81UPGP4R rill# <br /> AUTHORIZATION TO RELEASE INFORMATION:When applimble.I.the owner or operator of the property loafed aline above sda address.hereby authorfze the release of <br /> any and all results,geolecnnial data and/or envlronmemallsite assessment info mation to the SAN JOADuw COUNTY PUBLIC HEALTH$ERVICEs ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same Ilme it is provided to me or my representa ve. <br /> TYPE OF SERVICE REQUESTED: I I/ � — --�- - - <br /> COMMENTS: V� 1 <br /> PAYMENT <br /> APR 3 0 Asea RUSH <br /> SAN JOAOUIH <br /> SERVICES <br /> INSPECTOR'S SIGNATURE: ,f'�� I ISION <br /> APPROVED 9Y: (� I EMPLOYEES: (Doe) ` DATE: l <br /> ASSIGNED TO: -, EMPLOYEEe: C DATE �Z� <br /> Dale Service Completed (it already completed): SERVICE CODE: l P/E2� <br /> Fee Amount: 5 ' <br /> Amount Paid I Payment Date <br /> Payment Type V , Invoice 4 Check S Received By: <br />