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1' a <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST <br /> o C7 YG a <br /> & P <br /> OWN OPERATOR � n <br /> FACILIrY NAME <br /> SITE ADDRESSF�i ljGI�'y <br /> =from: <br /> MrwJbn 1 - \ Nam TVP SuN�tl <br /> Mailing Address (If DifferentfromSbAddress) ��gy <br /> Zip <br /> PHONE#'I W APN# LAND USE APPLICATION# <br /> PHONE#2 W. BOS DISTRICT LOCATION CODE <br /> CONTRALTOIR I SERVICE REQUESTOR <br /> REOUFSTOR, BILLING PARTY❑ <br /> �c 5 <br /> BUSMESS E � �-,� .PHONE# �• <br /> ADOR FAX# <br /> _ NNG G � <br /> c T -zo <br /> BILLING ACKNOWLEDGEMENT: I, the undesgned 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 with this projector activity Will be oiled to me or my business as identified on this loom. <br /> 1 also certify 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 INWS. <br /> APPLICANT SIGRk DATE: <br /> PROPERTYI&1S OWNER C OPERATOR I MANAGER ❑ OTHER AUniORRED AGENT ❑ <br /> IfAPKt Wisnxrhe8WNGPAmv.proof ofwdnr6adon m sign is(Mow Tice <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 amllor envi onmentaYSib assessment information to Me SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as d IS available and at the same time it l$provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECEPVFr <br /> DEC 18 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVIS I(" <br /> INSPECTOR'$SIGNATURE CONrRACroR's SIGNATURE <br /> APPROVED BY: E7IPLOYEEA: C - DATE: <br /> ASSIGNED TO: EYPLOYEEIk >t DATE (Z L <br /> Date Service Completed (If shady completed): SERvIDECoDE P1'E.a <br /> Fee Amount 3 b Amount Paid Payment Data <br /> Payment Type Invoice# heck# Received By: <br />