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01 SERVICE REQUEST <br /> Type usiness or Property FACILITY IC# SERVICE REQUEST# <br /> C9 <br /> OWNEIZ:ig)PERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NA <br /> 9 G <br /> SITE ADDRESS y-� � <br /> 3 0 / St"ILumber I DFrettlem DD 1�> S Street Names __ TYpe Suite a <br /> HOME or MAILIN ADDRESS (If Different from Site Address`) <br /> M1 <br /> CkrY N STAT) Z!P , 3 2� ; <br /> PHONE#1 Exr• APN# LAND UsE APPLICATION# <br /> 30 34 <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING At70RE5S <br /> BIISlNE55 NAME x I n A/(l� ` � PZv f'� Fxr, <br /> HomE or LFNG ADDRESS r 1 FAx# <br /> ® 79 I 14� - <br /> C17Y -7 / � STATE /' ZIP <br /> BILLING ACM'40 VLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC IIE•ALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that l have prepared this applicat' n and I}tat thew rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA Id <br /> F.ELJE <br /> RA <br /> APPLICANT'S SIGNA'T'URE: DATE: 9/P-1O <br /> PROPERTY/ BiJSINFSS OWNER OPERATOR MANAGER OTHE , T110 =ZEDAGEN <br /> /f,11'PLICAN7'is not the 814Ll G A.iRTY proof ofauthorization quired Tiels <br /> AUTHORIZATION TO,RELEASE INFORMA__T__IQN: When applicable, I, the owner or ator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnic ata and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES ENVIRON L HEALTH DIVISION as soon as it is available and <br /> at the sante time it is provided to me or my representative. ' <br /> TYPE of SERVICE REQUESTED:4//7 'Z,4 c''�L-0�A�/ �7Z(D1—>—,--VV v <br /> COMMENtS: �~ <br /> r�Q <br /> INSPECTOR'S SIGNATURE; f CONtRACTOR'S SIGNATURE: lVjglp�V <br /> APPROVED BY: / t EMPLOYEE#: DAtE: () <br /> ASSIGNED TO: ` EMPLOYEE#: (� DATE: <br /> Q <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 1 3cp Amount Paid _f Payment DateP3a1gc) <br /> Payment Type ►" Receipt # J!Check # 514 7,- Received By: <br /> t <br /> SRR1iQrev Jac 7/1/1999 <br />