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SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> G!< i <br /> FACILITY NAME <br /> T U c <br /> SaEADDRESS <br /> /3 c0 StrMNurro- Wesson saved Nam. SY Typ. sunee <br /> Mailing Address (If Different from Site Address) <br /> c 1,14 R R o <br /> CITY . STATE ZIP - <br /> A /' <br /> PHONE#') aT APN# LAND USE APPLICATION# <br /> yzsr °I f 1113 a7 7e- 61 7 <br /> PHONE#Z BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME PHONE# Esr. <br /> Rrr� k r -V Olf I �ry9 <br /> MAILING ADDRESS FAX# <br /> AlrIIAARV R D 12-7-ayH9 <br /> CITY i'/E AS AYV`%C h` STATE ,id LP 9y!r- <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 DlwsloN hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this 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. aa <br /> 7 �i <br /> APPLICANT SIGNATURE:/'n add )—)14jaz DATE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER J$ OTHERAUTHORIIED AGENT ❑ Al CR. <br /> OAPnlcwrisnofthe Bnis+c Pnarv.Proof ofauthorbadan to sign is mquuad 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 environmentaVsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: r - <br /> COMMENTS: <br /> 11AY111i=I4 1 <br /> t CCEIVED <br /> OCT 271999 <br /> SAN JOAQUIN COUN?Y <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: Q DATE: o y <br /> ASSIGNED TO: EMPLOYEE#: / DATE: Z b <br /> Date Service Completed (f already completed): !v Cf G7` SERVICE CODE: y a 11E: Z <br /> Fee Amount: ° Amount Paid Payment Date 97f <br /> Payment Type Invoice# Check# BGG Received By: <br />