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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REfl QUEST# <br /> OWNER/ OPERATOR CHECK It BILLING ADDRESS❑ <br /> FACILITY NAME r /�^ 1^ F>[--/ /�r-\N <br /> SITE Ap RE �ILlIV <br /> [SSLSIID45 SItaft Name 7vUa Suite e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 <br /> EAT. APN# LAND USE APPLICATION# <br /> 19/x ) 7Cggj z3 T <br /> PHONE#2 EAT• BOS DISTRICT LOCATION COOE <br /> (4JW IzD832 41G l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR p^ CI/ECK If BILLING ADDRJEXT. - <br /> BUSINESS <br /> "TE1cld: �� r� zr vC '`�T <br /> PHONE#NAME 6 2341HOME ar MAILING ADDRESSFuc#r 1 `� ZOLCITY / ,/� STATE /A ZIP rya c,4: 6� fJ <br /> RII 1 INC ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge [hal all site and/or project specific PUBLIC Ii EAI.TH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this Comm. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST d FEDERAL laws. �rfl <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/ BUSINEss OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT . <br /> IfAPPLICINT is not the 8ILLING P-49 proof of authorization to sign is required Title <br /> .UT110RIZATION TO RFI.FASF. INFORMATION: Wlmen applicable, I, the owner or operator of file properly located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sire assessment <br /> information 10 the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTII DIVISION as soon as it is available and <br /> at the same time it is provided to me Or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ' <br /> SEW 1�9 <br /> ,.UUtw ..,,uNTY <br /> PUSUC HEALTH SERVICES <br /> bWIRONMEN <br /> INSPECTOR'S SIGNATURE: 9-3-99 <br /> J-9S CONTRACTORS SIGNATURE: TgL HEALTH DIVISION <br /> APPROVED BY: O - t� ,C, EMPLOYEE#: Da� l I DATE: / <br /> ASSIGNED TO: E:.tPLOYEE#: �Qo \ DATE: <br /> Dale Service Completed (if already completed): SERVICE CODE: `L�Z P I E: I <br /> Fee_AnTount: U 6 Amount Paid Payment Dale <br /> Payment Type Receipt# Check it Received ey: <br /> 7/1/1999 <br /> SRIiliQrcvduc <br />