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• <br />SERVICE REQUEST is <br />Type of Business or Property <br />M rk)t Mir ,/ C��s sT4-rrv�' <br />FACILITY ID # <br />CommENTs: <br />SERVICERE <br />i <br />EST # <br />J <br />BILUNGPART^rX <br />C�f OPERATOR G N TF- 1,244---7 <br />1-14 <br />FACILITY NAME A ,� I 1A A P -T - <br />�V l /t/' <br />SAN JOAQUIN GU,,NI r <br />ENV 0MEN EA <br />SITE ADDRESS <br />HESERVICES <br />ALTiy <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR`s SPGNATU RE: <br />1756 sftVe Number <br />�IrecSon <br />G~' <br />sulm Sam <br />Ty" Surfs x <br />EmpLoY—aIf: `��� <br />DATE: <br />Mailing Address (if Different from Site Address) <br />74D1 6461FIC. fid KAJUC <br />CITY � -rO c v T -D/0 <br />!`EXT. <br />STATE Zip <br />/7 / <br />C� <br />PHONE #'i <br />(Zoo) - —75-3L, <br />APN # <br />SERVICE COOE� <br />LAND USE APPuwioN 9 <br />PHONE #2 EXT- <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR t SERVICE REQUESTOR <br />REQUESTOR _ 61LilNG PARTY fl <br />BUSINESS NAME PHONE # EXT. <br />MAILtNGADDRESSAl i�✓�r �^� W�V FAX# 7TV <br />1//Fd <br />CITY y 731,61e -MO C_ � �c� STATE Z'P �2-05 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that alt site and/or project specific <br />PUBtic HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly changes associated with this project or activity will be billed to me or my business as identified on this form. <br />I also certify that I have preps pplicatian and thaltaiyork to be performed be done in a=rdanoe Witt'+ all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: DATE* <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APmr w is not the Br 1 M Pum: Pmd ataut mdution to sign is mqukw Title <br />AUTHORIZATION TO RELEASE INFORMATION: when applicable, I, the owner or operator of the property kxated at the above site address, hereby authorize the release of <br />any and alt results, geotechnical data and/or environmentallsite assessment information t0 the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONK*mAL HEALeH OnnSioN as soon <br />as A Is available and at the same time it is provided to me or my representative. <br />TYPE OF SERvicE REQUESTED: <br />CommENTs: <br />DEC 1 1998 <br />SAN JOAQUIN GU,,NI r <br />ENV 0MEN EA <br />HESERVICES <br />ALTiy <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR`s SPGNATU RE: <br />APPROVED BY: �r, ��, \Q i <br />EmpLoY—aIf: `��� <br />DATE: <br />AssiGNED T0: "t"� L<� Ji ; <br />EmpLoYEE* �L� <br />DATE: 11-30 <br />Date Service Completed (If already completed): <br />SERVICE COOE� <br />P 1 E: ~' <br />Fee Amount: <br />Amount Paid' Payment Date <br />Payment TypeInvoice # <br />tJ 1 3 Check # Received By: <br />