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SERVICE REQUESTDq�7 <br /> Type of Business or <br /> nil <br /> ert FACILITY ID Ii S?XEORaEq•U�,STI� 0 <br /> I '` �vj <br /> OWNER OP ATOR /) Il.Llit_/ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME[' <br /> $IT/?PESS <br /> W 60 <br /> D TV Suite R <br /> sl[ssiNua4st�➢1[ast! <br /> HOME of MAILING ADDRESS (If Different from Site Address rauomit t✓f <br /> Cl <br /> CIN SAT /; ZIP — 1.26 <br /> PHONE NI ` EXT. APN N LAND USE APPLICATION# <br /> PHONE p1 EAT• BOS DISTRICT LOCATION CODE <br /> t <br /> ( I <br /> C NTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR - U /v' CHECK If BILLING ADDRESS <br /> PHONE JI <br /> EXT. <br /> BUSINESS NAtit <br /> HOME or MAILING A DRESS .�,{ •U- FAx# <br /> UJ (ce I <br /> CIN STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC III:ALTH SERVICES ENVIRONMENTAL HEALTII DIVISION hourly charges <br /> 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 prepared this Alication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard , S ,k td FEman <br /> laws. <br /> APPLICANT'S SIGNATURE: `lam - DATE: <br /> PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT iS not the BILLING P.IK7Y.proof of authorization to sign is requite Tutt <br /> AUTHORIZATION TO RFT EASE INFORMADQN: When applicable, L, the owner or operator of the property located at the <br /> above site address, hcieby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at dte same time it is provided to me or my representative. <br /> 7SERVICEESTED: il ZRECEVED <br /> FEB05 CONTRACTOR'S SIGNATURE: 'PN�PA01j <br /> EMPLOYEE✓T: ER <br /> APPROVED BY: `JGt�C�\ ©(�'QlI41 (TH CES <br /> ASSIGNED TO: \ EMPLOYEE#: DATE: <br /> Date Service Comp otod (if alr dy completed): SERVICE CODE: P I E: 2 <br /> Foo amount: �� W Amount Paid ��� Ob Payment Date <br /> Payment Type Receipt a Check 1F t f(C� Received BIt <br /> y: <br /> SRRf:0,cv,Joc 7/1/1999 <br />