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r <br /> 2 2 J <br /> SERVICE REQUEST �� 3 A 3 f <br /> Type of Business or Property FACILITY ID# SERV CE REQUES # <br /> OWNER OPERATOR <br /> BILLING PARTY❑ <br /> FAcnm NAME <br /> SITEADDRESS <br /> l/� �Str�rt Numbw f n ww Nam Type L Sao I <br /> Mailing Address (If Different from Site Address) <br /> Crry STATE ZlP <br /> PHO E#9T• APN# LAND USE APPLICATION# <br /> 051 - 3-10- 31i <br /> PHONE#2 BOS:DISTR>cr LOCATION CODE'. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REauEsrolst � BILLING PARTY❑ <br /> f i � <br /> BUSINESS NA1r1E I PHONE# Exr. <br /> ItitWLMG ADDRESS � i, /v � + FAX# <br /> �1V) Il Ln <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT; I,the undersgned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENMORONM .IAL HEALTH DrvLSrON hourly charges associated with this projector activily will be billed tame or my business as identified on this form. <br /> I also certify that I have prepared s application and that the work-to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws, <br /> APPLICANT SIGNATURE:, DAA: <br /> f <br /> I <br /> PROPERTY/BUSINESS OWNER CJ OPE R1MWGER ❑ OTHER AUTHORIZED AGENT 0 <br /> ftAvrf,cwris ref the 0umPARPY proof of aufho&atlon to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,t,the owner or operator of the property located at the above site address,hereby authorize VIe release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SER=Es ENvutoNmi:NTAL HEALTH DMSION as soon <br /> as it is available and at the same time it is provided to me o�rr my representative. <br /> TYPE OF SERVICE REQUESTED' <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JAN 9 2001 <br /> SAN JOAWiN COUNTY <br /> PUBLIC HEAL141 SERVICES <br /> ENV1RONhr1E N�A.L f)IV1510N s <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED 13Y:. Q EMPLOYEEM DATE: <br /> ASSIGNED TO: ,�� EMPLOYEES': 06`l DATE: <br /> Date Service Completed (if already completed): Z U ��� SERVICE CODE: p 1 E: <br /> Fee Amount: Amount Paid (-� D Z) Payment Date ` <br /> Payment Type Invoice#' Check# �r��-3 � EZeceived 8y: <br /> i <br />