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SERVICE REQUEST <br /> f <br /> Type of Business or Property FACILITY iD# SERVICE REQUEST# <br /> s G�oo�q <br /> OWNER I OPERATOR BILLwG PARTY 0 <br /> FActLITY NAME <br /> SrrEAooRESS 50 <br /> �� StrntNun�dv `Oban � Y 'G`-'�StrtieName <br /> ✓ Sui1�tl <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE Z <br /> PHONE#•l Ex*. APN# LANG USEAPP�LICA]TIooN# <br /> PHONE#2 ecr SOS DISTRICT LaeATTDN COM;- <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQuESTOR r ro Sum PARTY <br /> EMAMILINGADDRIESS <br /> INESS(ANE r— PHONE# Ezr. <br /> FAX# <br /> Ro BlouY „q 64— .STATE ZAP <br /> LING ACKNOWLEDGEMENT:1, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/orCprorooject specific <br /> PUBLIC HEALTH SERVICES E VIRONAiENTAL HEALTH OIVCSM hourly Charges associatEd with CHS project ar ac$*will be Imlled to me or my business as identified on this for n. <br /> I also certify that I have prepared this application and that the work su be perkmred will be done in accordance with all SAN JoAwN COUNTY Ordmence Codes Standards,STATE and <br /> FEDERAL laws. / <br /> cANT SIGNATURE: DATE:^/ —!4--6)/ <br /> PROPERTY!BUSINESS OWNER 0 OPERATOR/MANAGEROTTER AUTHORIZED AGENT � <br /> NAPPLCANrisnatfhe proolnrauCrerrraUonrosignixrrgrelnd TWO <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I.the owner or operatorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaYsite assessment information to the SAN JOAOuIN COUNTY Puux HEALTH SERVICES ENVIRONAENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: + <br /> i:• may'� �/�. <br /> CoMMENTs: PAYMENT <br /> `l” , rp ° S RECEIVED <br /> &W— G` /�� SAN JOAQUIN COUNTY <br /> _ PUBLIC HEALTH AL DIVA <br /> GES <br /> ''?l'iRDNMENTAL HEALTHH OlVl310N <br /> INSPECTOR'S SIGNATURE: CONTRACrOR's SIGNATURE: <br /> "APPROvEDBY:r 1 FyPL,—,YK.w#: DATE: <br /> ASSIGNED= l ,&^_6 EmPsOM11 DATE: <br /> Date Service Completed (if already completed): �,Z 7'U I: SERVICECODE: (Ej -P l'E-- <br /> EAm : Arhount Paid7Payment Date ��- fDI Dpe ✓ Invoice# Check# -7!0 Received By <br />