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�,. SERVICE REQUEST f <br /> Type of Business or Property FACILITY ID# SERVICE REQUE(S/T�A <br /> SSC (1�/ <br /> OWNER OPERATOR 1 6SLUNG PARTY <br /> FACILITY NAME <br /> STTEAD s ss,.x.ro.r FdLT 4//l M t/- o d. 121 <br /> Tro. sm.a <br /> Mailing Address (If Different from SiteAddress) <br /> CITY 3 7F X �, STATE �-+ l- S oL •S <br /> PH0NE#1 J bT' APN# LANOUSECAPPPUCATION# <br /> (z°) %3 / 35 70 <br /> PH0NE1 Z / aT• BOS DISTRICT `- LncATtoN COdE <br /> e <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR �- SLUNG PARTY❑ <br /> Zy <br /> BUSINESsNAME PHONE# En'.2, -5-� % <br /> MAILING ADORESS —3 -5 �, t3�%i��l JZa O Fze#1 fl 3620-1 J-r l <br /> CITY / ir1 ) STATE C4 ZIP (2— <br /> BILLING A[C.KKN(OWLEDG/EMENT; I,the undersigned property or business owner,operator or authorized agent of same.admowledge Mal s/de andlor project specific <br /> Pusuc HEALTH SERVICES ErimmAENTAL HEALTH Olvs®N hourly dharges associated with this projector activity will be tailed to me or my business as identified on this form <br /> 1 also certify that I have prepared N' port4=atork m he do w•m be done in aaprdanm witih ap Sav JOAOrN COIIHTY Ovdshence Codes,S(an aids,STATE and <br /> FEDERALlaws.APPLJCANT SIGNATURE' GATE'PROPERrYIBUSINESS ❑ OnFRAumP 2FDAGENT �C 7O IC <br /> I CAPPLC itnCtas proddauNarfatlen bsipn6ngeod' ` Title <br /> AUTHOR¢ATION TO REL SE INFORMATION:When appTmhle,L he ovvneraroperatorof the property bate <br /> at the above site address,hereby authoft the release of <br /> any and all results•geotechnical data aallor emironmentallsi a assessment bhfarmadon to Ne SAN JOAmN GouNrY PueLc HEALTH SERvIcES EwRONAENTAL HEALTH DIVISION as soon <br /> as it is available and at the same Ume it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> / I RECEIVED <br /> JAN 1-0 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: NEALTH.DEPARTMENT' <br /> APPROVED BY: ESu+tar>±4: C� C DATE: <br /> ASSIGNED TO: -"S EMPLOYEE#: �3 DATE: tJ <br /> Date Service Completed Cif already completed): SERYICECoo PIE 'i =1( : <br /> Fee Amount - Amount Paid c c; D D Payment Date I / r <br /> Payment Type Invoice Check# (F�12- - Received By: !�. <br />