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SERVICE REQUEST <br /> NusinesVrProp rty, FACILITY ID# SERVICE REQUEST <br /> 3 73� <br /> E O TOR._I/Iyllxp- n BILUNG PARTY 0 <br /> FACILrrY NAM <br /> SREA 151/1C <br /> / r Weccan $trNlXam TTP' SvNr/ <br /> Mailing Address (If DIr.6om r Qr(dresslr v ,� <br /> CRY STAT <br /> g02 <br /> PHONE#1 Ea. APN# LAND USE APPLICATION <br /> M d z� r l:z car <br /> P O #2 � _ O, EKTBOSDSTRICT LOCATION CODE. <br /> i <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUE ORy ,�t BILLING PARTXRr <br /> BUSINESS NAME 0,(1(,/'x/ Il. �� �• PNON #� _ � ,,F3+• <br /> MAILMG ADORE�SS /�/ /� ry 11 FAX# �/' <br /> C {( ?//y ,d TATE zip <br /> EIILCI�d ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that an site and/or pmject specific <br /> PUBLIC HEALTH SERVICES ENvIRONMENTAL HEALTH 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[artily that I have pre this application and Thal hp work to be performed will be done in accordance with all SAN JOAOu N COUNTY Ordinanco Codes,Standards,STATE and <br /> Iw <br /> FEOE .laws. //Jlqr �� <br /> APPLICANT SIGNATURE: DATE: ' <br /> PROPERTY I BUSINESS OWNER O OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br /> IlAart.cwris not the Bgiml` ..proofofaothortradon to sign is reguirad 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 environmentallsile assessment information to the SAN JOAQUIN COUNTY PUaue HEALTH SERVICES EwiRONMENTAL HEALTH Dmslom as soon <br /> as it Is available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: LAS 1 j Q <br /> COMMENTS: <br /> DC <br /> �..,.iL,_1' .. <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: c� DATE: <br /> ASSIGNED TO: ll EMPLOYEE#: ' DATE: <br /> .Date Service Completed (if already completed): - SERVICECODE: <br /> Fee Amount: 7 C,. Amount Paid n -7 Payment Date <br /> Payment Type ✓ Invoice#' Check 9 Received By: <br />