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Type of Business or Property SERVICE REQUEST 1C D �C I's <br /> p FACILITY ID# (Z0 <br /> AC-,Rl CutTupSERVICE REQUEST# <br /> i A Pry� 2csq—�t�_3 0 7-10 <br /> � <br /> OWNERI OPERATOR Lt SLI rgT,t B � <br /> B. <br /> FACILITY NAME SABILLING PARTY 0 I� <br /> C 9v1'E A 5 a��F�.�4pERA-��R <br /> SITEADDRESS <br /> (-14-7 <br /> 1ME �' <br /> -- street Numhw Otrettion A''� i 0 q - <br /> Mailing Address (if Different from Site Address, <br /> TyP' sell.r <br /> CITY <br /> PHONE#1 STATE !i. <br /> zip <br /> (209) Err APN# II <br /> 835 —803 O LAND USE bH# j <br /> PHONE#2 2C � t —-3 d — /r <br /> BOS:DISTtttcr <br /> 9 LOCATION CODE:. <br /> REQUE$TOR CONTRACTOR I SERVICE REQUESTOR <br /> kvy"O L Q C 271 s <br /> BUSINESS NA)AEIv> BILLING PARTY 0 <br /> MwPHONE# <br /> uNG AnDRFSS 2 <br /> �-1� MR�u t~v�r <br /> CITY FAx# <br /> STATE GR zIP <br /> BILLING ACKNOWLEDGEMENT: r, the undersigned property or business owner,Operator or authorized agent of same,acknowledge that aft PUBLIC"E N SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be bitted to Same,or <br /> site and/or projec#specific , <br /> also certify that 1 have prepared this application and that the work fO be performed will be done in accordance with an SAN JDAaUIN COUNTY OrdirrancOmy business as enCodesurled an this form. !j <br /> FEDERAL laws. <br /> Standards,STATE and <br /> APPLICANT SIGNATURE: ,F <br /> PROPERTY l BUSINESS( DATE: 6 cs <br /> d OPERATOR/MANAGER <br /> Q OTHERAUTHORIZED AGENT � <br /> fir Aaatx�rrr is not rho a�M Prudorauthodzatron to sin is <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,!,the Owner or OReratorof the roe ¢ raautrod � ~ <br /> G rrtra <br /> any an a)Fre sults,geotechnical data andlor environmentaVsile assessment information to the SAN JOAQUIN COUNTY PUBLIC FiEALTN SrA+ncCs ENVIRONMENTAL HEALTH ptVISrON a <br /> as it is available and at the same time it is provided tO me or my representative, Property�boated at the above sr#e address,here 1! <br /> by�O the release n <br /> TYPE OF SERVICE REQUESTED: s soon <br /> S cce.�Ac-� <br /> COMMENTS: � <br /> ;p <br /> a . <br /> RFCEIVED <br /> ° SAY 7 70Z <br /> N � SFQUIN COUNT' <br /> INSPECTOR'S SIGN TU!W- AN J\N J3OUBUC}iEALi4EA.LTk1 Dv10 SERVIGESSION <br /> NTR . <br /> APPROVED BY:. CONTRACTOR'S SIGNATURE: cs4 f,ilON4hFNiAL <br /> i <br /> EMPLOYEE <br /> - <br /> ASSIGNED-TO' DATE: I <br /> S• S 9 114 EMPLOYEE#: d <br /> Date Service Completed (if already completed}: 7 3 DATE: <br /> Fee Amount: ��°� <br /> SERVICE ConE .f.s '.P I E: . la 0 <br /> Amount Paid 1 7g' C� Paq <br /> Payment Type ✓ Payment©ate <br /> Invoice#' Check# <br /> Received By: <br /> I I <br />