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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID p SERVICE REQUEST <br /> r _ C-,:, (0 (96(D <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> (�StmNumeer r- n 7 Suss Nrmn T. Svml <br /> Mailing Address (It Different from Site Address) <br /> CRY STATE ZIP <br /> PHONE Xt E,n. APN S LAND USE APPLICATION p <br /> ( ) 7 eq - 060 — <br /> PHONE p2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQHFSTOR/ BILLING PAR <br /> PX C'c `1 z �� <br /> BUSINESS NAMEPHONE If pn. <br /> -- ------- �41 <br /> MAI 11NG ApORESS _ FAx N <br /> v o S " YR- SS / <br /> Cm (/4 /C— STATE Lf' //` ZIP 9 S`.� 6 <br /> BILLING ACKNOWLEDGE ME : I, the undersigned property or business owner, opanlor or euthorhe ani of same. acknowledge that all silo and/or protect specific <br /> PUBLIC HEALTH SERVICE RONMEN HEALTH DIVISION hourly charges associated with Nis pmjed or adM Ip be billed to me or my business as Identified on this form. <br /> I also certify Nal I h ve prepared Nis ap lcatio and Nal work lobe pedormed be nuance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. <br /> � APPLICANT$IGHA7URE: DATE: � <br /> PROPERTY/BUSINESS OWNER ❑ OPFJiATORI MANAG ❑ OTHER AUTHORIZED AGENT ❑ <br /> e r! ruf the esus PARrr.proof of sudiorhu ion to sign H required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I.the owner or operator of Ne property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmenlallske assessment Into matron to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVRONMENTAL HEALTH DWIsioN 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 /> COMMENTS: <br /> PAYMENT <br /> MAY 71999 <br /> SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH S[NVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATbPW!RONMENTAL HEALTH DIVIInOl- <br /> APPROVED BY: C, - _ (> EMPLOYEE'S: �� ( DATE: S <br /> ASSIGNED TO: iL�\ —�'-Y--R EMPLOYEE': O�� I DATE: gel <br /> Date Service Completed pl already completed): , Z� : 5,. SERVICE CODE: �—' S P I E:'L 6. O Z <br /> Fee Amount: Q /0 O Amount Pald 3Q Payment Dale 5- -71 q q <br /> Payment Type J Invoice If Cbeck 4 t77S Received By: L6 <br />