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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 r.., F�-a000s�� ��200 3�f8�-I <br /> BILLING PARTY❑ <br /> OWNER I OPERATOR <br /> FAcILRY NAME <br /> SITE ADDRESS 107 t-\ ThT--f--C- S7- 57— <br /> SeeetNuhMr oirereon Speet Nanw Tree SuNe7 <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> CrrY <br /> PHONE#1 AFN# LANG USE AP PLICATION# <br /> L.E'#2 <br /> � BOS OISTRtcT. Louttox CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING P <br /> REOUESTOR <br /> PHONE# ' <br /> BUSINESS NAME Ci <br /> MAILING ADDRESS FAX# <br /> Cm, STATEC�q zip <br /> 2-22 <br /> BILLING ACKNOWLEDGEMENT: I,the undersyned property or business owner,operator or authorized agent of same, acknowledge that all site and/or Project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated wAh this project or activity will be billed to me or my business as identted on this form. <br /> 1 also certfy that I have prepared this application and that the Werk to be Performed will be done in aanNance with at SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. B <br /> APPLICANT SiGNANRE:J���/ h DATE: /O� <br /> PROPERTYI BUSINESS OWNER Cl OPERATOR I MANAGER Cl OTHER AUTHORIZED AGENT itle <br /> IfAWUGwT is nu the 81 IN PAMY Proof Of authorioton M"On s'"U"Of <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1.the owner or operator of the property located at the above site address,hereby authorim the release of <br /> any and all results.geotechnical data andlor emdmnmenratsde assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION W soon <br /> as it is available and at the same lime it's provided N me or my representative. <br /> TYPE OF SERVICE REQUESTED: / S7— <br /> COMMENTS: C/CJ <br /> EC VED <br /> AUG 7 DO <br /> PUBLIC TI <br /> HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CORIAAL70WS SIIGNATURS' <br /> APPROVED BY: EMPLCYtstt <br /> ASSIGNEDTO: EMPLOYEE#: 8 7 DATE: D3 <br /> Date Service Completed (if already completed): $ERVILECODE - PIE: a3Q 0 <br /> Fee Amount ® ti Amount Paid a 7 O Ch Payment Date /p j <br /> Payment Type ✓ Invoice# Check# ,�DoT - Received By: <br />