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• SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY!D# SERVICE REQUEST# <br /> 1 <br /> /� BILUNG PARTY 13 <br /> OWNER f OPERATOR I w q Y J/ <br /> 1� 7� V SLr FiUtl u <br /> FAC[uTYNAME <br /> SlTEADDRESS ''IT + N M'41/I <br /> p RflMIT1C'N�Dk/Ir-C:Q+ N <br /> 1 /I sbvd Numhar Otnction Sb'eitNam! MIT <br /> I fl'P� Suits 3 - <br /> Malling Address (If Dif#erentfrom Site Address) <br /> CIfY y�� STATE C# ZIPAN Tj CA <br /> f <br /> M <br /> •+ LAND USE APPtjcAThoN# 1� <br /> PHONE#1 ' L7� <br /> (Za`0) 4 2,"e- 573:Z LOCATION CODE <br /> PHONE#2 EXT. BOS DISTR1c7 <br /> CONTRACTOR!SERVICE REQUESTOR <br /> BUJ14IG PARTY i7 <br /> REQU'ESTOR 6 <br /> PHON€# / Ea.BUSINESSN Me �� � rJ� 9[G Y� ` 6'. 6 <br /> �! FAx# / <br /> MAIuNG ADDRESS �0 ,n �/p (c yl�v (o V-7 <br /> f'f/ STATE 6,4 LP G� S g � <br /> Cm -5-At .2�+cr-r`� <br /> e or business owner,operator or authorized agent of same, acknowledge that all site and/or project speaSG <br /> BILLING ACKNOWLEDGEMi NT: I,the undersigned p rty� will be Filled to ma or my business as identified on this form. <br /> PUBUC HEALTH$ERvicEs ENwRONmENTAL HEALTH DNMLCN hourlycharges associated with this di+rity <br /> project or a <br /> I also cenify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL Iaws. DATE-. / / <br /> 9/ //,0-z- <br /> APPLICANT SIGNATURE; /� <br /> OTHER AUTHORIZED AGENT Cl I v d.,f�i+� IM,�7'�7A�-'L•`t <br /> PROPERTY I BUSINESS OWN ❑ OPERATOR I MANAGER rUp"L/ Title <br /> K APPt,r-Wr is W d"6104Furrw proof of sutlr kudan to sign Is"k-ed <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,t,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all resufts.geotechnical data arWar environmentadlsite assessment information to the SAN JOAOuIN COUNTY Puauc HEALTH SERMC S ENVIRONMENTAL HEALTH DNIS ION as soon <br /> as it is available and at the same time tis provided to me or my representative. <br /> TYPE OF SERVICE REI]UESTEU: t <br /> COMMENTS: <br /> INSPECTORS SIGNATURE: CONTRACTOR'5 SIGNATURE: <br /> APPROVED 9Y: <br /> EMPLOYEE#: DATr-* <br /> ASSIGNED TD: <br /> EMPLOYEE#- DATT <br /> Date Service Completed (ff already completed): <br /> SERvtc€CODE: _ .1 � E' Z <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type <br /> Invoice# Check# Received By: <br />