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SERVICE REQUEST * i <br /> rType of Business or Property FACILITY 10# <br /> SERVICE REQUEST# <br /> `.� �1�RtC:Lat PL�rs aM�5t <br /> OWNER!OPERATOR gRAp t lo s BtLUNG PARTY❑ <br /> S <br /> FAciuTY NAME <br /> SITE ADDRESS Rc>,gD <br /> SVeefHvmber orrectian <br /> SVW Name Type Suites <br /> Mailing Address (1f Different from Site Address) <br /> N/A <br /> CITY STATE GJ� Ep 953a4 , <br /> PHONE#1 APN# <br /> L <br /> { _ 4lfD USE APPUCATiON# <br /> �1 �s�1 BS DLST = LO <br /> PHONE#2" S4� �� C i ia'�- Ptd�l`1 , OCATION CODE P' <br /> CONTRACTORI SERVICE REQUESTOR <br /> REQUESTOR 1AALT9R r--, CUT;mS 13WNG PARTY <br /> BUSINESS NAME G�� �.[�1�� Q PHONE# fJcr. <br /> MAILING ADDRESS 4,1 Sm ASN tW PLAZA t # �,� <br /> CITY STATE <br /> CA ZIP 993Z4-0 <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andlor project specific I <br /> PuBuc HEALTH SERVICES ENVIRONMENTAL HEALTH DrAMN 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 Ihis application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanca Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPUCANT SIGNATURE:_ _ DATE:- <br /> PROPERTY I BUSINESS OWNER <br /> ATE:PROPERTYIBUSINESSOWNER ❑ OPERATORIMMAGER ❑ OTHER AUTHORIZED AGENT _G�vLL F-1 G 1 k-1 <br /> If Amr-wr is not tha Bung Pyrrr proof of aufhonza Uan to sign is roquirvd Title <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 /> any and all results,geotechnical data and/or environmentallsite assosament information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERvrCEs ENvvtoNMrNTAL HEALTH DfvisoN as Soon <br /> as it Is available and al the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ReYiV-V1 SOIL- ol-r^E41-11t 57VZIy <br /> COMMENTS: r' <br /> .PAYMENT <br /> RECEIVED <br /> AUG 2 o 209'1 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAi HEALTH DIVISION <br /> - r <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. v[ EMPLOYEE M ` DATE: <br /> ASSIGNED-TO: EMPLOYEE {: 7 r7 DATE: <br /> Date Service Completed (if already completed): SER+ncECQDE' ..P/E:2-&,O <br /> Fee Amount: {`7 9'o.`—'- Amount Paid �rr� -- Payment GDate � � v <br /> Payment Type Invoice p' Ciyecft# <br /> 4{ Received By: <br />