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• SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 000 E. 6— ;' <br /> .�o �c�e5 FT�m( I 2� <br /> OWNER]OPERATOR r (—I�mI � PArTOXAS O BILLING PARTY <br /> FACILITY NAMEL,4 CA <br /> C <br /> (Sf,rjE A'D7DR SS SV C1iJ L4 G Cam <br /> Street Number DireNon CAP f 1�L A•g4eet.4ame Type suke% <br /> Mailing Address (If Different from Site Address) <br /> CITY O I T STATE <br /> 0 A ZIP q� � A <br /> PHONE#1 exT. APN# LAND USE APPLICATION# <br /> (Z�) o .55 -�Zp-Z4 <br /> PHONE#Z Ear. BOS DISTRICT LOCATION CODE <br /> r ) � <br /> CONTRACTOR i SERVICE REQUESTOR <br /> RFOUESTOft 7 BILLING PARTY <br /> oNV Mi KA c IC In x&2-4 <br /> BUSINESS NAME <br /> dv C6D Eo V iR �,eP^L �� c . (2 NE# 46 <br /> 7- 100 <br /> MAILING ADDRESSOD� e So1,/ FAx(I # T —j ' � S <br /> CITY -STOC <br /> �/-M w p wI STATE CA, zip 957-05 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andicr project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 aocordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL BWs. rrBf� ( /��J�- ,1 <br /> APPLICANT SIGNATURE: / r Vf _ DATE: D /Z�/y <br /> O <br /> PROPERTY!BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ r�E%7F.Q)!09(S� <br /> ;rApptl6Wris Prot the BrwNC Panry Proof o/authorization to sign is required 'itle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authonze the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same lime it is provided tome or my representative. <br /> TYPE OF SERVICE REQUESTED: OF rr �'7 /10 P S— � 7 <br /> w � Cee ffluV <br /> COMMENTS: V r� <br /> FJ,Ay Ct y <br /> CMY 22M <br /> 3AN JOAQUIN Ci.,ui,I r <br /> PUBLIC HEP-LTH SERVICES <br /> cNVIRON!,4ENTTAL WEALTH DWISIOr, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: 3 EMPLOYEE#: OC)Q <br /> ASSIGNED TO: VK I -U. �(J1Nl Q_ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1'E: <br /> Fee Amount: 3-Bn7 = 3s( °� Amount Paid 3 °�_ Payment Date <br /> Payment Type Invoice# Check# R - Received j <br />