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SERVICE REQUEST <br /> 'type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER{OPERATOR BILLING PARTY <br /> /t'i rt • P IVA VARIZ-A IVA VA-1Z A �RoT`f/,1z, Q, L a3E7R'T A✓A Kit q <br /> FACT TY NAME t�R o PE <br /> ;. <br /> i // t <br /> SrrE,400Rrrss 5 T <br /> j p J WwNumber Olrectian S7eetNxn. Type <br /> SuN.af <br /> Mailing Address (if Different from Site Address) <br /> A ; :... : <br /> STATE zip <br /> Cm / L CA S <br /> PHONE#'I EXT. APN# LANG Use APPLICATION# <br /> a; <br /> PHONE92 <br /> EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> BILLING PAM <br /> REQUESTOR <br /> Do nl CLI�s�IE <br /> BUSINESS NAME PHONE#ell <br /> _ <br /> MAILING ADDRESS FAX# <br /> P. C) , L3oX 379 <br /> CITY 2 L STATE C q ZIP 9S3 8 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andfor project specific <br /> PUBLIC HEALTH SERvas EtMRCNµENTAL HEALTH DrnstoN hourly charges associated with this projector activity will be billed to me or my business as identified on this form <br /> t l also certify that I have prepared this ap I' tion and that theto be performed will be done in accordance with all SAN JOAQUIN Coum Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. �—/( — O <br /> APPLICANT SIGNATURE: DATE <br /> PROPERTY l BUSINESS OWNER 0 OPERATOR l MANAGER OTHERAuTHORIZED AGENT <br /> IfAPPLcmris not rhe —proof of authorization to a/prr rs nagu* Title <br /> AUTHORI7A71ON TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property totaled at the above site address,hereby authorize the release of <br /> any and all results.geotechnical data and/or environmentallslte assessment information to the SAN JOAQUIN COUNTY Putiuc HEALTH SERvxEs EwRoNMENTAL HEALTH Divism as soon <br /> as it is available and at the same lime it is provided to me or my representative. <br /> TYPE OFSERVICE REQUESTED: ` Ir7ZA7 �A/ !/ �rluP RFv(Ev') <br /> IZ <br /> COMMENTS: 5`Z3-ZOOd <br /> f k4"4 �� �� RECEIVES <br /> � SAY <br /> • SAN JOAQUIN COUNT'r <br /> PUBLIC HEALTH SERVICE <br /> ENrVtA1ONMENTAL HEALTH DlVtsiU;v <br /> 5- <br /> Z3-2000 <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY.. EMPLam#: �D� l DATE: <br /> .-ASSIGNED-TO: EMPLOYEE#: DATE: <br /> .Date Service Co pletcd (if already completed): SERVICECODE 2 P.f E:: jjt •, <br /> Amount Paid 0� 7Payment DateFee Amount: <br /> •rF zd-uct <br /> Payment Type invoice#' Check# Received By: <br /> y S <br />