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SERVICE REQUEST <br />Type of Business or Property <br />44 � E2SG �.' <br />FACILITY ID # <br />BIWNG PARTY 0 <br />SERVICE REQUEST # <br />OWNER I OPERATOR <br />COMMENTS: <br />BILLING PARTY ❑ <br />FACILITY NAME <br />��� c�� <br />SRE ADORE S <br />SStreet Number <br />ant <br />(� <br />EType <br />SuN� l <br />Mailing Addre (If Different from Site Address) <br />[TY F� E��aj o <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />( <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />APPROVED 13Y:. <br />� <br />S:DISTRICT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />GA2 � <br />44 � E2SG �.' <br />BIWNG PARTY 0 <br />A.) <br />COMMENTS: <br />BUSINESS NAME <br />r+ c <br />��� c�� <br />PHONE # <br />ExT• <br />MAILING ADDRESS <br />(� <br />FAX # <br />MAR 19 2001 <br />[TY F� E��aj o <br />STATE C g <br />ZIP ?9 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project 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 certify that I have prepared this application and that the work to be performed will be done in accordance with alt SAN JOAOUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL lays. <br />PPLICANTSIGNATURE: , • <br />PROPERTY/ BUSINESS OWNER <br />OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />DATE: 3—/ ( -0 <br />40 E,62 v. a e- -7-'.--x /f <br />IrAPPucwr is not Bw Burn Purry Proof of authorisation to sign Is mqulrvd <br />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 environmentallsite assessment information to the SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICEs ENvutONLIENTAL HEALTH DIVISION 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 />` <br />COMMENTS: <br />PAYMEN I <br />RECEIVED <br />MAR 19 2001 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONh1FNTAL HEAITH DIVISION <br />INSPECTORS SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVED 13Y:. <br />� <br />EMPLOYEE #: COD I <br />DATE: <br />\ <br />AsSIGNEDTO:f/\ C a- <br />EMPLOYEE 9: 00 U <br />DATE: <br />Date Service Completed tf already completed): <br />SERVICE CODE: (� <br />P 1 E: 2 <br />Fee Amount: 2 ( (L ' <br />Amount Paid 0 --TPayment <br />Date r7 <br />Payment Type <br />Invoice #' <br />Check # 50 <br />iiiece By: <br />