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_ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S�VI E REQUEST# <br /> OWNER OPERATOR <br /> BILLING PARTY D <br /> FACILITY NAME <br /> SITEADORESI <br /> J Strnl Numbr grernan �C�( J �V 15yN(Nnn� � J —� �� SoN�f <br /> Mailing Address (If Difterent from Site Address) <br /> CRY STATE Zip <br /> PHONE#1 �*• APN# n LAND USE APPLICATION# <br /> I ��- �� -� <br /> PHONE#2 Ev. BOS,DIS7RICrI LOClSION CODE' <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR <br /> /1?<���c n r BILLING PARTY <br /> /t Dw <br /> BUSINESS NAME � '/ Q PHONE# Ecr. <br /> fT' % �•CF,f y�.St'Y;p l��i/sxaPm�t,7- SGC <br /> MAILING ADDRESS f� <br /> Z�JaI �f /Ni4-t1T / .I G/QC,c£ FAx# ��// <br /> Y/J"7Z77C <br /> CITY STATE <br /> xrGT�tJ LP -5-90 <br /> BILLING ACKNOWLEQGEMENT: 1, the undersyned property or business owner,operator or authorized agent of same, acknowledge Ural an site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity win be billed tome or my business as identified on this form. <br /> 1 also minty that I have prepared thi pplication and that the work lobe performed will be done in aomrdance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. /L <br /> APPLICANT SIGNATURE: DATE: �" —/O/ <br /> PROPERTY I BUSINESS OWNER OPERATORI MAMA Cl OTHER AUTFIOIUIEp AGENT 0 <br /> IlAPgA'iwr is not rho Bum PAarw Woctofsuthorhadon to sign is mqukvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1.the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geolechnical data and/or environmentallsite assessment information to the SAN JOAOIIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH ONISION 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: �\I` S, •I n '�1,-( ( m k <br /> COMM-HT — <br /> ��iZ�o <br /> PAYMENT <br /> YD/ �/ �iJ� c✓/ G"'� � '� '�^' J — RECEIVED <br /> k�w�l �� <br /> SAN JOAQUIN COUNT), <br /> PUBLI/ (,r ENbIPONMENTAtLIH EAERVICE'w'N <br /> INSPECTORS SIGNATURE:' CONTRACTORS SIGNATURE: Ip l <br /> APPROVED BY:. L' (.. EMPLOYEE M `/��L DATE: <br /> ASSIGNED TO: s S�--A.•`J EMPLOYEE 9: > /';/''�kz \ <br /> Date Service Completed (if already completed): SERVICECDOE: <br /> 52Cj PIE: d <br /> Fee Amount: S Oma_ Amount Paid <br /> k{q5, DZ) Payment Date <br /> Payment Type Invoice# Check# <br /> 51 Received By: <br />