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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE h R� T�EOUEST# <br /> OWNER OPERATOR 60 L 3� <br /> BILLING PARTY❑ <br /> FACILITY NAME <br /> SREA1DDDR7ES�$L,-stn/� �^ n <br /> o`- 1 Dire on © L,ll Street xan. <br /> Mailing Address (If Different from Site Address) Ty', <br /> sw.A <br /> CITY STATE <br /> zip <br /> 01$ 53Z <br /> PHONE#1 Fat APN# LAND USE APPLICATION It <br /> ( ) <br /> PHONE#2 Err. OS DISTRICT LOCATION CODE <br /> r , <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR r <br /> C.� u _( (" � BILLING PARTY Cl <br /> BUSINESS LANAE V„VV(N^���.• V r PHONE Tp�, <br /> I <br /> MAILING ADDRESS r ^ � & lFAX# <br /> CITY l 6 <br /> STATE C <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION hourly charges associated with this project or activity will be billed 10 me or my business as identified on this form. <br /> I also CerBly that I have prepared this application and that the work to be Performed will be done in accordance with aU SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. 'v�A <br /> APPLICANT SIGNATURE: / L.CIi / DATE: `iA <br /> /l//O 0 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTIORIZEDAGENT ❑ _ <br /> IIAPFUriwrls not dpd rUMEA- Proololaud"Irstim to sign is raquhad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release r>t'- <br /> any and all results,geolerhnical data and/or environmenUgsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEAL iH SERVICER ENVIRONMENTAL HEALTH DwIR�1 as soon <br /> as it is available and at the same time it a provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: \ J <br /> 3AN JOAUUIN COUNTY <br /> • -NVI,,Ui3UC SERVICES <br /> RONlMENTALLTHEALTH DNIS101' <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: M1>90 <br /> V�LJ DATE: <br /> ASSIGNEDTO: L- EMPLOYEE#: DATE: <br /> �n4W <br /> .-Dale Service Completed (if already completed): �� <br /> SERVICECOOE: -.!.� p I E[ Q <br /> Fee Amount: �' Amount Paid , <br /> Payment Date <br /> Payment Type Invoice#' Check If <br /> Received By: <br /> ///r: <br />