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—' SERVICE REQUEST <br /> r Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LOM rerlAL S2 0lb ZZ Z1-00 <br /> OWNER OPERATOR BILLING PARTY p <br /> /J`ZiJ/N/ lcNiIEG <br /> FACILITY NAME <br /> tV-/—Z' A/ EF'T" ES <br /> O <br /> SITEADORESS <br /> 3 / 2FN��1 <br /> SbM NN��4nrm.. <br /> Street Huinbaf Wecuon iYe. $Yeas <br /> Mailing Address (If Different from Site Address) <br /> CITY/ a STATE ZIP <br /> PHONE#'I j r — Esr. ApN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT - LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BLUNG PARTY <br /> BUSINESS NAME L C ✓/<,�I[/ /I <br /> �� PHONE# (GFL6�'-/W0� Ear. <br /> MAILING ADDRESS �C� Fes# <br /> CRY / STATE / LP <br /> L C%G ` c <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 ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this projector aclivity will be billed to me or my business as identified on this four. <br /> I also certify that I have prepared this tion and thwo, to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. r7 <br /> APPLICANT SIGNATURE: - DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> IIAPHrvwrisnof , BuwGPurry poolofauWodzadontosignlsrequimd 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 and/or environmental/sile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: _ <br /> N/T2 g7-F ZaAAI-J STUD r SOIL 54/>fl a [/ STCC D '-e V/E0/ <br /> COMMENTS: <br /> RECEIVED <br /> aa�j MAR 2 8 2000 <br /> � � IZjam S cNViRO!VMENTAL HEALTH <br /> `' �t�� PERMIT / SERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. - EMPLOYEE#: 104D-�1 1 DATE: <br /> -ASSIGNED TO: EMPLOYEE#: �.� tit DATE: <br /> .Date Service Completed (if already completed): - SERVICE CODE: PIE: A'—c - <br /> Fee Amount: 2,C ��i Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />