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SERVICE REQUEST <br /> Type of Business or Property FACILTY ID# SERVICE REQUEST# <br /> k K Co f o063�O 1 s�oO�S�7 <br /> OWNER OPERATOR BILLING PARTY 0 <br /> FACILITY NAME , <br /> SITE ADDRESS <br /> le 4, D sa..tN.mbr Wecdon o 0 7YL l S <br /> Mailing Address (If Different from Site Address) q <br /> CrrY JC 7— G !< TO N STATE <br /> PHONE#1 Ear• APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 Ea. BOS;DIsTRIcr LOCATION CoOE:. <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Cb -n e- I T BILLING PAR <br /> BUSINESS NAME _ PHONE# Ea. <br /> e 7�- CoAjT a- c7-r-) s 46t - 633 -/ <br /> MAILING ADDRESS FAX# <br /> 3s tom ,' tv tc r . 41 (0/ - 6 3 4 'T' <br /> CRY s C '� e) / y STATE ,G� ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site annddfor(/project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION hourly charges associated with this projector activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this ap licafion and that the wo to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS ER 0 OP R/MANAGER 0 OTHER AUTHoFuzEDAGENT 0S®-./2 S A" 9 <br /> I/Aan.cwrisnot Nell rm Pum poofo/authorhadon to sign is npukvd Title <br /> AUTHORIZATION T ELEASE INFORMATION:When applicable,1,the owner or operatorof the property located at the above site address,hereby authorize the release or <br /> any and all results,geotechnical data and/or environmentallsile assessment information to the SAN JMOUIN COUNTY PUBLIC HEALTH SERVICES ENvLRoNMENTAL HEALTH OmSION 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: ` n 1 <br /> COMMENTS: <br /> I) � <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVEDBY:. ( .� IPaid <br /> EE#: C)Lq-r� ( DATE: <br /> ASSIGNED TO: fr' I S EE#: ©� l.J DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3,' P/E: Z-50 <br /> Fee Amount: (0 Am (r / Payment DatePaymentType Invoice#' Check# Re eivedBy: 'v_ <br />