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SERVICE REQUEST' o* (p <br /> Ty • FACILITY ID SERV( EQUEST <br /> pe of ss or I <br /> OWNER OPERATO CFIECKIf BILLING ADDRESS❑ <br /> ^� <br /> FACILITY NAME ! �� l� � % �C`;` �• � ,�!l <br /> SITE ADDRESS <br /> r N b 1 /�L� IvetNam • I e I SUiteu <br /> ISSS.lr�LSL4 <br /> HOME Or MAILINGDRE If Dlf I e m Site Ad <br /> CITY / �� lil� �� ^TATEZZ <br /> PHONE#1) ExT� APN!S LAND USE APPLICATION ti <br /> a _ <br /> PHONEY /� _ Exi. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQ TO ��^ CHECK If BILLING ADDRESS <br /> / J , <br /> Busii)iii N ME ' S66 pl E ,}17- <br /> Ext. <br /> HOME Or M DRFU FAx <br /> CITY �/ 1 f��AFE ZIP <br /> BILUNG fNG ACKNOWLEDGEMENT: 1, the undersigned property or business `owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTII SERVICES ENVIRONMENT,\L HEALTH DIVISION hourly charges <br /> 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 prepare is a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stu dards, TF�and F' E laws. <br /> APPLICANT'S SIGNATU (v � Q DATE: ��-Z��' <br /> PROPERTY/QIISINESS OWNER <br /> OPERATOR/MANAGER OTIIER AUTIIORIZED AGEN <br /> If APPLIC4NT is not the(iILL(NG PARTY proof of authorization to sign is required Tlrf r <br /> AUTiTORI7AT10N TO RELEASF INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES ENVIRONMENTAL HE•ALTII DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �—- 2_C� LC 6V— t t= <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> SEP 2 8 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: ENVIRONMENTAL_HFAITH DIVISION <br /> APPROVED BY: EMPLOYEE#: C')e o_ n_ DATE: <br /> ASSIGNED TO: WV (�� EMPLOYEE#: -7 5�7 DATE: <br /> Dato Servico Complotod (if (ready complete SERVICE CODE: ��' FIE: <br /> Foo Amount: L C' Amount Paid Payment Date II_�-c7b <br /> Payment Type L,kL2� Receipt# Check # ( h Recoived By: <br /> SRItliQrev Juc Q/k 1/1/1999 <br />