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SERVICE REQUEST �. ..i <br /> Type of Business or PropeKy ACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR BILUNG PARTY❑ <br /> FAciuTY NAME / <br /> SITE ADDRESS /� ///�n �D <br /> sVWNu oh.c000 Ow�y�Jif`^ sx..r xame Tya. SW.a <br /> Mailing Address (If Different from Site Address) <br /> CITY ( _{ It . STATE /y ZIP - <br /> r f'( <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATgNCODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PAR <br /> BUSINESS NAME f _ PHONE# <br /> /lam/It <br /> MAILING ADDRESS D/� FAX# <br /> f U Gly1 /7 <br /> CITY � STATE C-4 ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site ardlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION houfly charges associated with this project or activity will be billed to me or my business as identified on this fano. <br /> I 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 laws. <br /> is z <br /> APPLICANT SIGNATURE: � "'� DATE; A <br /> /°/�J✓�� <br /> PROPERTY I BUSINESS OWNER 11 OPERATOR I MANAGER ❑ OTHERAUTHORIZED AGENT R[ C4 LYi Sl.lpg&U1 S44't_. <br /> IfAroLcaNris not Me BA i m Pa ,proof ofauthortzadon to sign is mquhad TiNa <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: r14 <br /> Qou> /- a / <br /> COMMENTS: OftJ /OU r(�_L�o�V/6// <br /> //sr /S/F�YJI,.v <br /> M0D& GQ abn� <br /> e' <br /> PU,-n --/- <br /> RECEIVED <br /> -LRECEIVED <br /> DEC 9199 <br /> SAN JOAQUIN COUNrY <br /> PUBLIC HEALTH SERVICES <br /> INSPECTOR'S SIGMA CONTRACTORS SIGNATURE: ENVIRONM <br /> APPROVED BY:. .�^ EMPLOYEE#: (� //��j DATE: <br /> ASSIGNED TO: EMPLOYEE#: 7 'L DATE: 11 J I <br /> Date Service Completed (if already completed): O SERVICE CODE: PIE: <br /> Fee Amount: '�a 3'f U U Amount Paid 34O U Payment Date /.;I-Ig r9 9 <br /> Payment Type Invoice#* Check# �sSZ)C Received By: <br />