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0 • <br /> SERVICE REQUEST <br /> Typ f Busine s or Property FACILITY ID# SERVICE REQUEST# <br /> OW RIOPERATOPir _ U/T ffu BILLING PARTY <br /> FACILITY NAME 0 <br /> IT RESS_ •W <br /> SbM NumEs rection V46h (/��j 5trM Name / /9 <br /> . Tyr. Sera <br /> Mailing Address (I Di a nttLfrom Site / f� /7• <br /> CITY <br /> L//C L / lo' o TA - ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> Y 90 ala - <br /> PHONE92 Exr• BOS:DISTRIcr LOCATION COOE'. <br /> D - 5 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQU TOR BILLING PARTY <br /> BUstN S A PHONE# / <br /> MAI ADORECS;.-�;l F # G� <br /> C —k 02t(Ld <br /> TATE ZIPO <br /> BILLIN ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PueuC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION 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 pr this appligtion and that N work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: / DA : <br /> c <br /> PROPERTY IBUSINESS OWNER 0 OPERATOR/IJArAGER ❑ OTHER AUmomzw AGENTVL- <br /> I/AevucAurisnorNBurvcPurr'r.pmfofauNorizadonfoslpnisrKuirvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,L the owner or operatorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOALUIN COUNTY PUOUc HEALTH SERVICES EIMRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time ilia provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 1 / <br /> COMMENTS: .` PAYMENT <br /> RECEIVED <br /> MAR 13 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED DY:. EMPLOYEE#: DATE: <br /> ASSIGNED TO: M!j L EMPLOYEE#: �� S` I <br /> DATE: <br /> Dale Service Completed (if already completed): SERVICECODE: 71 I E: <br /> Fee Amount: / Amount Paid Payment Date <br /> Payment Type Invoice 4' Check 9 Received By: <br />