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SERVICE REQUEST <br /> FACILITY ID 9 -^ SERVICE�EC�I�.E,ST � <br /> Type of Business or Property <br /> c` LJ� <br /> CRrC r CA L <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS <br /> ❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> N e Type � Suite ax <br /> street NL,mber I Irectig0_ <br /> HOME Or MAILING ADDREESSS (If Different from Site Address) <br /> 3-3600 "' , �7� STATE ZIP <br /> CITY <br /> ExT. APN# LAND USE rAPP CATION# <br /> PHONE#1 M �j .- <br /> ( ) / , (i <br /> PHONE#2 ExT. <br /> BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> [:i <br /> p CHECK If BILLING ADDRESS <br /> v � �� PHONE ft --E-XT. <br /> 9 �/ �� <br /> T- FAx# <br /> RESS ( I <br /> ,�EIZ n G ZIP <br /> STATET! .—YD <br /> : 1, the undersigned property or business owner, operator or authorized agent of same, <br /> BILLING a( li,�OWLEDGEMENT <br /> specific PUBLIC HEALrii SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> acknowledge that all site and/or project <br /> to me or my business as id <br /> associated with this project or activity will be billed entified on this form. <br /> I also certify that [ have prepared this applic ion and that work to be performed will be done in accordance with all SAN 1onQU►N <br /> COUNTY Ordinance Codes,Standards, S and FED _ s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> OPERATOR/MANA('F.R ER:\UTIIORIZED AGENT <br /> PROPERTY/ BUSINESS OWNER tred Tirle <br /> If APPLICANT is not the HILLING P.IRTY proof of aril/ ri at <br /> I HORIZATION TO RFLEASF INFORNIATI N' When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data an(�/or environmental/site assessment <br /> ]able and <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SFRVICES ENVIRONMENTAI,HEALTH DIVISION as Soon as It is avai <br /> at The same time it is provided to me or my representative. <br /> TYPF OF SERVICE REQUESTED: SO�` S� T��3/L �7Y STS �t/s -- <br /> COMMENTS: AW2 4' <br /> Ww <br /> JMIV Jkd+UUIN CO1Jp1TY <br /> ENVIRONMENLIC TAL HEALTH L7�dffy�w <br /> CONTRACTOR'S Sir NATURE: <br /> INSPECTORS SIGNATURE: —-- -----—- <br /> --- — EftPLOYEE#: I DATE: <br /> APPROVED BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: p f E: / <br /> SERVICE CODE: <br /> Date Service Completed (if (ready completed): <br /> Fee Amount: Amount Paid /Sw OG- <br /> Payment Date <br /> CfTeck # Received eye <br /> Payment Type Receipt# _ r <br /> 7/1/1999 <br /> SRRFOrev doc <br />