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i • e , <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ,r,4 39 SERVICE REQUEST# <br /> r , 'tel -,?-2-2 <br /> Am/Pon <br /> BILUNG PARTY❑ <br /> OWNER OPERATOR <br /> '6b2. 82 b <br /> FACILITY NAME <br /> SITE ADDRESS �j ' <br /> 13-,50 ShM Numb 0inctian <br /> 1" St}1� StrhtN ryp� SuM�3 <br /> Mailing Address (If Different from Site Address) <br /> ATV1 e_ STATE LP <br /> Cm <br /> PHONE#i APN# LAND USE APPLICATION <br /> 001) <br /> PHONE St'L aT SOS OtsTxlcr LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY❑ <br /> REQUESTOR A <br /> 'jam`• PHONE# �' <br /> BUSINESS NAME p�e-�(6_') �f'GG�� • M <br /> FAX <br /> MAILING ADDRESS (� -,�y, �7 <br /> Big) 2 <br /> CITY .'J SCT "V1 h1 e Wv"C.� STATE C4 ZIP 17c) <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andlor project specrx <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMs10N hourly charges assadated with thio proles or activity will be billed to me or my business as Idenf*d an this form. <br /> I also certify that I haveP d ppficadon and that the work to be meed wia be done in a=rdance with a0 SAN JOASUIN COUNTY Ordinance Codes,StandardS,STATE and <br /> FEDERAL laws. <br /> DATE: <br /> APPLICANT SIGNATURE: <br /> OTHER AL HOR�D AGENT or-Ifel S';W,r, 6e)f' <br /> PROPERTY/BUSwESS OWNER ❑ OPERATOR/MANAGER <br /> dwNarhadan to sip isrpulnd Title <br /> YAPPUCAHTfanarft8CUN* PAY <br /> AUTHORIZATION TO RELEASE INFORMATION:When appfabie.L the owner or operator of the property located at the above site address,hereby authorize the release of <br /> 10N <br /> any and A MuIS,geotechnical data and/or en hor mentaUsBe assessment information m the SAN JOAOUw COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OmSa9 5edr1 <br /> as it is available and at the same time d is provided to me or my represented". <br /> TYPE OF SERVICE REQUESTED: C R � C^Lel ct� L t Y,JQ u7 -g l ) I Pj U L <br /> COMMENTS: •3CP�C�NEO <br /> R <br /> SEP�6��2 <br /> SP g`O NOP NE0 <br /> 014, <br /> N�N-10 <br /> EN PONMEN�I <br /> INSPECTORS SIGNATUR CONTRACTOR'S SIGNATURE: <br /> EMPLOYEE t. C DATE <br /> APPROVEDBY: <br /> ASSIGNED TO: (;. EMPLOYEE#: 8C DATE: <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: ! 'PlE. Z,3 �: <br /> Fee Amount Amount Paid Payment Date <br /> Invoice# Check# Received By: <br /> Payment Type <br /> 1 <br />