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�. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# / <br /> OWN R1qFERATOR BILLING PARTY <br /> FACILITY NAME r r <br /> SITE ADDRESS `/.�,Y^��4`�^' <br /> G Z bM SNumbe D Spee Nam Type Suke6 <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#'I APN# LAND USE APPLICATION# <br /> 04 3 - 60k <br /> PHONE#2 BOS DismicT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAM PHONE# <br /> —833 <br /> MAILING ADORES FAX# <br /> SQ8 ,a �f- <br /> CITYST-in mrZ ZIP Qdroo <br /> BILLING ACKNOWLEDGEMENT: I,th dersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> Pusuc HEALTH SERVICES ONM AL H DmSIoN hourly charges 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 appl h andl_hat the-work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: I DATE: <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER 2/ OTHER AUTHORIZED AGENT ❑ <br /> aAl'PL'L+Wrisn0tflre Baine PARrv.pmdufmdtwJndantosignureeuind Title <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 environmentaUsfte assessment information to the SAN JOAQUIN COUNTY PUBuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as k is available and at the same time it is provided to me or my representative. 1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �/yy ■rr��r yy1py,T/r`ti <br /> ���ryPryJ`OppYvvGNE��7m 0 <br /> i'9Ea,r EIVUi <br /> DEC 81998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SI GNA E: CONTRACTOR'S SIGNATURE: <br /> "FRRVED BY' ' (� _ V t , Q„e EMPLOYEE III: COO DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE: I24 <br /> Date Service Completed (if already feted): SERVICE CODE: PIE: 2 <br /> Fee Amount: b c)c) Amount Paid Payment Date y o <br /> Payment Type Invoice# Check# 1 i/ Received By: <br />