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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR BIU.IHG PARTY Q <br /> FACILITY NAME <br /> WE ADDRESS I1 8>4 77:-75- <br /> � ' �..�Numbs olracaan Strrae nam. ryp. suFle a <br /> Mailing Address {If'Different from Site Addressl <br /> GIrY STATE y1 ZIP / S-3 76 <br /> PHONE#1 Fsr• APN# LAHoUSE APPLICATION <br /> PHONE#2 BOS DIVWCTLOCATFOH CODE:. <br /> CONTRACTOR ISERVICE iTEQUESTOR <br /> REouESTOR BILLM PARTY <br /> � /V s , <br /> BUSINESS NAME I/ PHONE / <br /> A <br /> LIINGADDRE55 � FRX#v?A2 LD srAlE ZIP 5- <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business ovmer,operator or authorized agent of same, acknowledge that ad site ardor <br /> project speafrc <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Oivcm houdy charges associated with ttus projector activity will be bmlled to me army business as identified on this form. <br /> I also certify that I have prepared ' ppliration an the YmFk to be performed will be done in accordance with ad SAN JOAcuiN COUNTY Ordinance Codes,Standards.STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATu.RE:. Dare' //�3 a o <br /> PROPERTY I BUSINESS OWNER Cl OPERATOR I 0 OTHER ALrnw AGENTfI ? e8UMPAanpvdofalatotrontosigp <br /> fs Title - - <br /> AtITHORIZATION TO RELEASE INFORMATION:When applicable.1.the evmer or operator of the property Ieraled at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data aneVor emrironmentaVsite assessment information m the SAN JQAQUtN COUNTY PUBLIC HEALTH SERVICES ENVIRONuarrAL HEALTH DIVISION as soon <br /> as d is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REOUESM: 7-4 <br /> COMMENTS: <br /> PAS NAEN <br /> eau ql Tdil-'v <br /> SAN SCAC3G!N CO:.,r t <br /> " /^� t Eh�t�Crh`t;i-t�fAl c}i-,A,1 N r�11'"`•' <br /> INSPECTOR'S SIGNATURE: L "CONTRACrojes SIGNATURE: <br /> APPROVED BY: r EyPLoy--1: J�7 DATr-: I1 B <br /> k ASSIGNED TO: �` EMPLOYEE#: �?0 DATE: <br /> f <br /> Date Service Completed (if already completed): Sa.itvlc>:C oD • 'P 1 E: <br /> eQ <br /> Fee Amoun4--X� =Amount Paid 41~ Payment D to <br /> Payment Type ✓ Invoice 9 b Check# +�3 Received By;:� <br />