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�!- SERVICE REQUEST <br /> Type of Business o:PrOp:erq1y FACILITY ID# SERVICE REQUEST# <br /> AL�RICGfL2/�L RE 5 . SR0 9 1J LQ I� <br /> OWNERI OPERATOR BILLING PARTY❑ <br /> /Cf/A217 ��Tfl� �/O <br /> FACILIrY NAME t <br /> AL-7/V U 5 MEA7 D1',1�FA <br /> SrrEADDR ss <br /> � StrM Numbv 114ecean 12 F Vc%2•T A>- /> <br /> SUMN., To. S0.9Mailing Address (If Different from Site Address) <br /> PC-) , BOY 927 E c � oma✓ <br /> CITY STATE LP <br /> PHONE#1 Fsr. APN# LAND USE APPLICATION# <br /> ( GYP9 - '-2 <br /> PHONE#2 Ea. BOS,D6TRICT LOCATION CODE' <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> lJ Iv C • t <br /> BUSINESS NAME - PHONE# Ezr. <br /> EAiQ R—JE5G=A(;—C " �nGs3- 14 3 <br /> MAIL.RIO ADDRESS <br /> FAx# / <br /> O • L3 0 _,l' 7 e <br /> CITY L STATE i'� A LP / <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 ENVIRONMENT TH OmSION hourly charges associated wilh this projectoractivity will be billed to me or my business as identified on this form. <br /> I also certify that I nave prepared this pr Uon and That the be performed will be done in accordance with all SAN JOAOUIN CouNry OrdinanceCodes,Standards,STATE and <br /> FEDERAL laws. /J 2 <br /> APPLICANT SIGNATURE: G1 -G� 2 DATE: / <br /> 0 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHERALTHoRIIED AGENT 11I/AaarcAwrisnoffhe . P ,ppaafafaufAwiradonfoslgnisregulred Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,i,the awner 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 JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it B available and at the same fime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> F /`1 N/1C E/'9ENi P A1V EViEW <br /> COMMENTS: <br /> PAYMENT <br /> RECFIVEF <br /> 1. <br /> i J'Jni�U P1 i <br /> iJth -1i i.i Jill <br /> r <br /> INSPECTOR'S SIGNATURE: p �, CONTRACTORS SIGNATURE: <br /> APPROVED BY:. „mµ__µ{ EMPLOYEE M D�� i DATE: <br /> ASSIGNED TO: �` 'L `6.C.� EMPLOYEE#: �?? d ` DATE: <br /> Dale Service Completed (if already completed): SERVICECODE: 5 -PIE: <br /> Fee Amount: I Amount Paid Payment Date <br /> Payment Type Invoice#' I Received By: <br />