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SERVICE REQUEST <br /> Typ of Business or Property FACILITY ID# SEM <br /> c r na 3�9 OWNERI OPERATOR FACILrTY NAME C— <br /> SR AIOlr n slanamr �� <br /> Mai ff Addr ssr fif Differ nt froT Slle Address) <br /> (� ( c- <br /> CITY('� � I � STATE � � ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# 5 Vll <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQIIF.STOR � / O BILLING PARTY CI <br /> 0 P— <br /> BUSINESS�JE• PHONE# <br /> I <br /> MAILING ADDRESS Z Fax# <br /> COY SSTATE //1 ZIP q <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 /> Pusuc HEALTH SERVIcEs ENVIRONMENTAL HEALTH QNISION hourly charges assocated with this project or activity will be billed to me or my business as Identified on this form. <br /> I:Iso certify that I have prepared this application and that the wark to be performed will be done in accordance w•ilh all SAN JOAOUIN COUNTY ONinance Codes,Standards,STATE and <br /> F=EDERAL taws. DATE: C/ <br /> / <br /> APPLICANT SIGNATURE: �+ <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER �.� OTHER AUP40RIZED AGENT Cl <br /> AIAPgA.wrisnotfle&a Plgrv.Xcolafaurhornadon W sign is requkad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property Iocated at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or enwronmentallsite assessment into motion to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DrvtSION as soon <br /> as.1 is available and at the same time it is provided to me or my rep esennttadvee-.mss,, <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYMENT <br /> yAyp p E NT <br /> 6�"P��Y�7I�YEijr: <br /> APR 2 61999 <br /> PUBLIC WEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: I EmPLOYEE#: DATE: <br /> ASSIGNED TO: �( I`li-- 11 1` EMPLOYEE.: ©O DATE: _ 9 <br /> Date Service Completed (If already completed(. SERVICE CODE: nJ (' PIE: <br /> lf— <br /> Fee Amount: 0 Amount Paid ���, ('v I Payment Dale i(I <br /> Payment Type o I Invoice# -!2Check# a y � Received By: 41 <br /> J <br />