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SERVICE REQUEST ~ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR - BILLING PARTY❑ <br /> Ir <br /> FACILITY N <br /> SREADDRESS 'w.AA� y�,pr..�.�1/rw•- ''�q �1 nAAAL <br /> o Street Numba Direction O Street Wme Type SuiteI <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE G LP - <br /> PHONE#1 a ExT. APN# LAND USE APPLICATION# <br /> (2 - I <br /> PHONE#2 Ext BOSDISTRIcr LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR I BILLING Pum <br /> a <br /> BUSINESS NAME I PHONE# En. <br /> 5 7 <br /> MAILING ADDRESS FAX# <br /> MT5 0q 9 933 OSSrY <br /> Cm , STATE ZIP 5 q <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,acknowledge that all site andror project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OmsloN 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 prepared this application and that the work to be performed will be done in accordance with all SAN JoAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. `\ 1` <br /> APPLICANT SIGNATURE: / V C' - I�Y t-� DATE:-��, <br /> 11 <br /> PROPERTY/BUSINESS OWNER OPERATOR/f NAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAvPtw'avrisnd Bte Bfl PAmr.Proof of authorization to sign is required 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 ano all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EtrnRoNMENTAL HEALTH DmsloN 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: <br /> COMMENTS: � �p <br /> PJY+ h'p,q/MMENT <br /> RLIS14 WT200009 RUSH <br /> .i Lwin(Y <br /> PUBLIC HEALTH <br /> SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. 1 EMPLOYEE } DATE: <br /> ASSIGNED TO: 1 / EMPLOYEE#: 1 DATE: <br /> Date Service Completed (if already completed): - SERVICE CODE: 3 P I E: 3(� <br /> Fee Amount: 136 Amount Paid Payment Date - ,,57 UG <br /> Payment Type Invoice#' Check# Received By: <br />