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SERVICE REQUEST <br /> Type of Business or Property FACILTiY ID# SERVICE REQUEST## <br /> 2V S <br /> OWNER/OPERATOR BeLING PARTY <br /> u <br /> FACILITY NAME 1� . <br /> ' Ct <br /> SITE ADDRESSL-f` fGt <br /> 2-3002-300SnMRumEer � GA..tRama <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#I W APN# LAND USEAPPurAwm4 <br /> ( <br /> PHONE#Z BOS DISTRICT LOCATION CODE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY Q <br /> I e5,e--<-7 rTL�S� <br /> BUSINESS NAME PHONE# �• <br /> -VZAL— p r'z L:.J 1 12-0 2 7,l i) I k-b o 'Lti 3 <br /> MAILING ADDRESS = Fax# <br /> b177-1 vJ Qd\.3a�� Fjt� 1p 765- `f`lo'b <br /> CITY? ZIP <br /> i-rir: \' f1A SNAG-n <br /> BILLING ACKNOWLEDGEMENT: I, the undetsgned property or business ewer,operator or authorized agent of same, acknowledge that ad site andlof project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OIVts10N howdy,charges assocaled with this project or activity will be billed to me or my business as identified on this foam <br /> I also canty that I have prepared this a bon and that the work m be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> ...tat FEDERAL laws. ^ / / / <br /> /\ APPLICANT SIGNATURE: , v DATE: A�( 6 ! d / <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AuTHQRIZED AGENT ❑ <br /> YAia isncllfal3aiwcPMn.p d fwtharha0m to sign is roquind 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 of <br /> any and all results,geotechnical data andlor environmemdltsite assessment information tD the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALON DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> 1 TYPE OF SERVICE REQUESTED: e'pt C V`Ca��„ (1(z r- t C_ <br /> COMMENTS: v <br /> �/ .1 2 U <br /> , ` <br /> .Yd/yJ[iCeKn- r// L/ PaYA/IEfV , <br /> RECE(vFr <br /> f]EC F <br /> SAN JOAQUIN ut <br /> Tr Lz, (.,k , . '� '� h PUBLIC HEALTH gEF;, . <br /> INSPECTOR'S SIGNATURE: Ctlmnucmfes -� 5 <br /> APPROVED BY: �/ EMPLOY--#: 4115- <br /> 1/ DATE: <br /> ASSIGNED TO: b EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed �C .b 2- 10 SERVICECODE: S ZZ 'P I Ec[�2� Z <br /> Fee Amount =' - Amount Paid / 75 - Payment Date 'p <br /> Payment Type Invoice# Check# 3 g 8 Received By: <br />