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0 <br /> Type of Business or Property SERVICE REQUEST <br /> FACILITY!D# <br /> SERVICE REQUEST <br /> OWNER/OPERATOR '(4 <br /> G b it �IBiLbNGOA11iTY <br /> FACILITY NAME <br /> S[rEAO KESS `dG,�LG DAP <br /> Sff�etNumAer Orre[tian SfffKNam� <br /> Mail <br /> (If Different from Site Address), ryp. s�rr.r <br /> XA <br /> M CrfY / /y � 9� <br /> L oo J STATE + Z1P <br /> PHONE#7 APN# ' <br /> LAND USE APPUGATfom# <br /> PHONE#Z <br /> ' 80S:DrSTTT>cT LOCATIONAODF�. <br /> REQUESTOR CONTRACTOR/SERVICE REQUESTOR <br /> 91> BILLING PARTY 4 <br /> BUSINESS NAME rr C <br /> PHONE# ExT <br /> MAILING ADDRESS <br /> 3 <br /> e FAx# <br /> Eny �da7 <br /> 4 STATE III zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONNrF�ITAL HEALTH DmsION hourly charges associated with this project or activity will be billed to me or my business as identified on thts form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance wilh all SAN JOAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: <br /> DATE: <br /> I PROPERTYIBUSINESS QWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT <br />} A� <br /> I(AomuGwrisnotfhn v�y ❑ <br /> [i3r�.t?,�oter,vm�:uarr to 119„rs,eqUlr� T-;uo <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,geotechnical data and/or environmentallsite assessment information to the SAN JOADUIN COUNTY PUBLIC HEALTH SERVICCs ENVIRONMENTAL HEALTH DIVISION as soon <br /> f as it Is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: IL 11 <br /> I <br /> COMMENTS: ' <br /> PAYMENT <br /> RECEIVED <br /> FEB 0 4 2009 <br /> SAN JOAQUIN COUNTY II <br /> -ALTH ONMENTAt- <br /> FiF.ALTH DEPARTMENT <br /> INSPECTOR'S SIGNATURE: <br /> APPROVED BY:. CONTRAC70R'S SIGNATURE: <br /> D L t U& t t EMPLOYE/:#: 032-1 DATE: <br /> ASSIGNED TO: 4 <br /> f�'t>✓Q!N f� EMPLOYEE P 3 DATE: <br /> Date Service Completed (if already completed): 06/ <br /> SERVICECODE' <br /> Fee Amount: j �0 AmDUnt Paid �q [— 525 P!1=:. 2J � <br /> eL' _>a 0-0 Paymr:nt Date t�v <br /> Payment Type ✓ Invoice>X' , <br /> Check 9 <br /> —7M Received By: � <br />