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I <br />SERVICE REQUEST <br />Type of Business or Property <br />SLUNG PARTY ❑ <br />FACILITY ID n <br />SERVICE REQUEST # <br />MAILING ADDRESS / <br />ocoo 9i <br />CITY C rb E <br />STATE �: Z!P >j;? : - <br />�OWNER <br />\I O�PWTOR �f <br />6-LE✓Gill 62ewA-L <br />STUNG PARTY ❑ <br />lJ�l "6/VtirG' -7A/G/4,V.j <br />/ T <br />FACiUTY NAME <br />SFTEAoDRESS f 3e) `j ^ <br />A,/ <br />I <br />oU,con <br />S�e,ryn. <br />ENVIRONMENTAL HEALTH UIVI310N <br />�Ya� <br />swu S <br />Mailing Address (If Different from Site Addressl <br />�� <br />_ o3 7C <br />/ <br />j t;; FPr<C r r•SC <br />E�IFL.E 1 Z i� 2 <br />CITYSTATE <br />,!L�q.✓r .4 <br />ASSIGNED T0: j r U <br />ZIP <br />c' -A X533: <br />PHONE #"I EXr• <br />APN K <br />LAND USE APPLIOATiON n <br />SE MCE CODE: -Y 4�'� <br />P I E. � 3 <br />PHONE i' 2 aT• <br />SOS DMRICT <br />Payment Date ' <br />LOCAwN CODE <br />qL } )) yy <br />Invoice # <br />Check # J <br />Received By: <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />SLUNG PARTY ❑ <br />BUSINESSNAhi,J <br />.,10/ i7/iV/E�%./uLC �S-;-r,f/CilIAti �r1.�, <br />PHONE# Exr <br />� <br />MAILING ADDRESS / <br />FALX# <br />CITY C rb E <br />STATE �: Z!P >j;? : - <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sane, admcwledge that all site and/or project specific <br />PueuC HEALTH SERvtcEs EwRGNLENTAL HEALTH DNrwN hourly charges associated with this project or actvity will be billed to me or my business as identified on this form. <br />I also cerity that I have prepared thisXapnt1h:e:w:r;k to be cored wid be done in ac=r ance with all SA:4 JCAOUuv COUNTY Ordinance Codes, Standards, STATE and <br />FEOERAIIaws.APPucANTSIGNATU `�DATE. <br />PROPERTY / BUSINESS OMMER ❑ OPERATOR / MANAGER Cl OTHER Alrr'riGRm AGENT <br />If Avfu-.wr �- not rhe Bum Purr proof of xrdxvd don to s;qn Er mgiinW Title <br />AUTHORIZATION TO RELEASE INFORMATION: When appricab{e, 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 ank-Vor emironmentaUsite assessment information to the SAN JoAcuN COUNTY PueuC HEALTH SERvicEs EwRoNuExrx HEALTH DnnStGN as soon <br />as it is available and at the same time it is provided to me or rrrf representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />13AYMENI <br />RECEIVED <br />AUG 14 2002 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH UIVI310N <br />INSPECTOR'S SIGNATURE: <br />CONTRACMR'S SIGNATURE: <br />AP PROVED BY: / } /, . <br />(�i j� <br />E�IFL.E 1 Z i� 2 <br />OAT"^_: -' 1 <br />ASSIGNED T0: j r U <br />EHPLOYEE#-. <br />DATE <br />Date Service Completed (rf already completed): <br />SE MCE CODE: -Y 4�'� <br />P I E. � 3 <br />Fee Amount –�-Cl <br />Amount Paid — <br />Payment Date ' <br />Payment Type <br />Invoice # <br />Check # J <br />Received By: <br />1� <br />