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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SE I(C�E REQUEST# <br /> �ar �roctd �Acl � I ��� <br /> OWNER/OPERATOR <br /> {� BILLING PARTY❑ <br /> l7Vfz`I., Tr>.� �o2Tv��(LnJ Aw.,rA FE tL.w Co <br /> FACILITY NAME <br /> Mpr Lxeasa �R'TG4.,v.o ODaL FACT�.T T•( <br /> SOE ADDRESS V;Tv R-OA-r-> <br /> S4aal NYmOar WecUon SIrM Name <br /> Mailing Address (If Different from Site Address) T"a sm"' <br /> CITY _ e� <br /> ST❑uc–v otj STATE ZIP ^72 <br /> :PHONE#'I rsr. �AP # LAND USE APPLICATION# (� <br /> PHONE#2 V - 91 – Z 1 <br /> [xr. BOS DISTTDOT ' <br /> ..�. LOCATION 000E <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> .e 62 1 .y BILLING PARTY <br /> BUSINESS NAME <br /> PHONE# • <br /> MAULING ADDRESS <br /> Q FAx# <br /> C rY <br /> STATE ]gyp <br /> BILLING ACKNOWA <br /> the u ' nod property or business owner,operator or aulhar¢ed agent of same,acknowledge that all site andlor project specific <br /> PuouC HEALTH SERVICDmS10 oudy rha�ges asso6ated with This project or aCliviry will be billed to me or my business as identified on this form. <br /> I also Certify that I haveti Thal the Ork to be Performed will be done in accordance with all SAN JOADUIN CWNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws.APPLICANTS NATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OOPERAT /NVSNGEAOTHERAUTHORIZEDAGENTD.NLScBN�AUTHORIZATION TR ON:When appligblO,I,the ovmcroroperatorof the property boated at the above site address,herebyauthorize the release of <br /> any and all result;,gCItOlt moat data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUDLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at Vic same time it u provided to me or my repmsent Uve. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ` t ( �COMMENTS: <br /> EN(,j CU <br /> 0 5 2000 RECEIVED <br /> PERM TSR "110y DEC 6 2000 <br /> ("`� 5 SUb 1 — �� ( -S• SAN JOAQUIN COON <br /> INSPECTOR'S SIGNATURE: 11 ENVIRDNMCsNiA(LTH SERVICES <br /> ry <br /> oI <br /> APPROVED BY;, CONTRACTOR'S SIGNATURE: <br /> EMPLOYEE#: A <br /> - TO: � <br /> EMPLOYEE#: -DATE: <br /> Date Service Completed (if already Completed): <br /> FecAmount: <br /> Amount Paid $ERVIC Couc PIE: 7/0 <br /> 5/ O)_' _ <br /> PaymcntTypc 35 Payment Date I � 5 U <br /> .�,�.�,{�� Invoice#' Check# C1 <br /> Received By: <br />