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SERVICE REQUEST EHGWISR revised OW4 Type of Business or Property '95rTE'S A h b FACILCfY ID# F T . AtaRtcu�~rUfLAt r, OMERI OPERATOR G FCr E• C--MM) 4.150- ftAR cREE1~V,V1REYA?-b5 It tc- - - - FAcnmNAME SAME A5 0WNE9-/C?ER R SffE ADDRESS VQO A1,0 16 jF C L M T � ROAfl `ate+ A bFL�55 — Shpt Vuftv Oir�tion 1 R WeK Nso� Mailing Address (E DifRrent from Site Address) I Wl14VNMAS-EVVW( MIA;LI NC, #1MRE--5 tot BEAR CRTEEK VIN"ARMs INT- CrrY Lodi �- -- _ - STATE CA ZIP 952 r-> fl PHONE 01 APN# G 5l-' OO` L4MD USE A,PP=TIOtt# ?�7- 04VO c''S 1-70 _ PHONE#1 orr. Bt?S D�rRtcT LorJtTIONCOUE 209 333- is I S CONTRACTOR I SERVICE REQt1ESTOR REOUESTOR BUM PARTYR 901NEss NAME SµMIE A5 P-tE0uZ:!trM1Z PltattE# BEL 4{ MA1LINr3 ADDRESs 4-16 M Ate{%eW P L.AzA FAX# �A CtrY t~o�l STATE [', ZIP '9524.0 BILLING ACKNMEDGEMENT: I, the undersigned property or bueiness owner, operator or authorized agent of sante, acknowledge that all 5fte and/or project specific Ptlam HEALTH SeRmEs EHvIR0t*A 4TAI HM?H©tYmm hraurty charges associated with this proqeoct or activity wiB be bitted to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JoAaum COUNTY 0n:Wance Codes.Standards,STATE and FEDERAL laws. APPLICANT SIGNATURE: DAM it-99 PROPERTY I BUSWEs R ❑ OPERATOR l MAKW" � Rst�4tm�AGENT ❑, �t�rri- �t��IS��? NAPRi Wls not the 8� r proofof eudiv►:r ft to sib is r+gi*ed rills AUTHORIZATION TO RELEASE INFORMATION:when appscable, I, the owner or operator of the property located at the agave she address, hereby authorize the release of any and aB results,geotechnical data and/or environmerftita to assessment irrfam"on to the SAN JoAourN CourrrY Pusuc HEALTm SERvicES EwRDNMENTAL HEALTH DBAsioN las soon as R is available and at the same time R is provided to me or my repromntative. TYptdoFSERwEREquEsm: SAIL SL)rrABlLL1'Y 1S.Fo4 t'l -SuP-F-^cE= ARD SUS�tJ�FACCr co p��rtt 'ttp P'G pot r PlEv trE W -� colymem Q SPECK GOxnrWWo )OFAPERovu❑ OTHER ❑ JhA 411 � G 1999 cc INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: QATa: APPROvea BY:. OL EMPLOYEE& r 2 QAW: AsMED To: EMPLOYEE it: DATE: Date Service Com eed (if already► ed: d SERWE ConiP i E: f Fee Amount: J Amount Paid 1�r� t Den //it /,get Payarent Type Invoice# Clradr# 13 or 1,6.