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a SERVICE REQUEST <br /> Type of Business or Property FACILITY ID k SERVICE REQUEST# <br /> RE . IT)E/V TIAI 2 ''0 <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> M 2 e <br /> FACILITY NAME <br /> SITE ADDRESS N �A Vi S <br /> / 7 Sbaat NumAe Wecean SbM N+ma Tma Suxaa <br /> Mailing Address (If Different from Site Address) <br /> CITY G 6' STATE LP <br /> iJ I � 5 2¢2 <br /> PHONE#1 EST. APN# LAND USE APPLICATION III <br /> PHONE#2 EXT. BOS.DIsTmcr LOCATWN CODE' <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR BILLING PARTY <br /> Do,v C,y�S/VE <br /> BUSINESS NAME A _ _ PHONE# Ezr. <br /> /4-D� <br /> MAILING ADDRESS FAX# <br /> P. e 3 L68--;? <br /> CITY I U STATE /' ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent or same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity,will be billed to me or my business as identfied on this form. <br /> I also eerily that I have prepared Nis t©ton and tha work to be performed will be done in aoaudance with all SAN JOAOuIN CcuNrY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: l7, DATE: <br /> i <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGE ❑ OTHER AUTHORuzEO AGENT Q <br /> IIAPgswvr is nor dv Burs Pura Proof ofaurhorizadcn M sign is requkvd Title <br /> AU TH 0 R IZATION TO RELEASE INFORMATION:When applicable.I,the owner or operalar of the property located at the above site address,hereby authorize the release of <br /> any and all results,geolechnical data and/or environmentallsile assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Division as soon <br /> as it is available and at the same tree it is provided to me or my representative. <br /> TYPE OF SERVICE REDUESTED: <br /> o;L TA 5; L / y/1F 1-(/ <br /> PAYMEI <br /> COMMENTS: <br /> ���y V <br /> FlC� ESI S4ur.S "" 1 S(/ a� — ,�3�oi RECEIVEr <br /> J q v Ao (Po <br /> L� L <br /> INSPECTORS SIGNATURE: CCIRRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: ( � DATE: <br /> ASSIGNED TO: EMPLOYEE 9: 9 C DATE: <br /> Dale Service Competed (if already completed): L ,v SERVICECOOE: <br /> Fee Amount: 1 / 00 Amount Paid ; �70, 0-j Payment Date <br /> Payment Type ,r Invoice# Check �(� Received By <br />