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SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST#ice �� <br /> fNOI,lST prL lel fCu� ��L <br /> Do q <br /> -OWNER l OPERATOR BILLING PARTY 0 <br /> A. 6, M- Pomo Pre iv <br /> FACILITY NAME <br /> SITEADDRESS Cj �3AW-rA <br /> �G SU s1r.�Nu,ab.r Dlretdort sezr corn,. ,y,p. sin.e <br /> Mailing Address (If Different from Site Address) <br /> CITYSTATE ZtP <br /> PHONE 91 err. APN# LAND USE APPLICATION# <br /> - Olt 017 070 62 <br /> o 4967 <br /> PHONE#2 *• SOS DISTR:cr LocA,TIDN CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQGESTOR BILLING PARTY <br /> BUSINESS RAME PHONE# Mn: <br /> A _ 2 �la d- l4-o 3 <br /> MAILING ADDRESS FAX# <br /> 0 3 taloS �-Zsf� <br /> CrtY l fL L STATE S 3 <br /> BILLING ACKNOWLE GEMENT: I,the undersigned property or business owner,operator or authorkmd agent of same, adurowtedge that all sde and/or pmject spea6c <br /> PUBLIC HEALTH SERVICES EWRON&CKTAL HEALTH OPAS[ori hourty charges associated with this project or activity will be billed in me or my business as idwtfted on this form. <br /> I also certify that I have prepared ppfication an the work to be perfnmted will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> ApPucANT SIGNATURE: DATE' <br /> PROPERTY I BUSINESS OWNER' <br /> Q OPERATOR IMANAG@R Q OTHERAUTHOPIZEOAGENC <br /> If APKXvrr Noor fhe ftda proofof W&Wtmdon to a finis mq.*a 'rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> arty and ail results,geotechnical data andlor emrironmentallsite assessment informadon to the$Ari JOAQUIN COUNTY Pu mjC Hmrri SERvms EwRoNmEWAL HEALTH OMSION as soon <br /> as it is available and at the same time it Is provided to the or my representativve. <br /> TYPE OF SERVICE REQUESTED: <br /> ire TF La Di � Sv � SLr' � ria ar �✓ill,✓ . <br /> COMMENTS: <br /> -S-rUDI� ui✓lS ln-'f a s '7`c c. �t kr•�.J,F�IL ; TL• G- <br /> PAYMENT <br /> RECEIVED <br /> SAN JOAGIUIN COUNTY <br /> "t.L. -rA!.k* ZOCY� �o4l_ ZJu CqA L PUQLIG HEALTH S=RVISES <br /> .ENVIRONMENTAL HEALTH UIVSISN <br /> GVSPECrOR'S SIGNATURE CoNnmcroFes SiGHATURE: <br /> aZ <br /> '.APPROVEDBY: —J�— Eu1 aY-ff:, Dip ( DATF: — Z�- d <br /> ASSIGNED To: S 1� EmKOYEE 3 bC DATE: <br /> Date Service Completed (if already completed): SERVICECOM. P!E <br /> Fee Amount Amount:Paid Payment Date l i 27 6 <br /> Payment Type ✓ Invoice 9 Check# 3 Received By: <br />