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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (<if I A L <br /> OWNER OPERATOR BILLING PARTY❑ <br /> ET S 12C AlZ1A ZEC-AT- 13e6ED-1 <br /> FACILITY NAME <br /> f O/2 C <br /> SITEADDRESS I /L W �/ <br /> 's � Str•w NumEer aimton /� / SeMNam• Typ• Surto: <br /> Mailing Address (If Different from Site Address) <br /> CN"( STATE CA ZIP 2 7 <br /> PHONE#1 �• APN# LAND USE APPLICATION# , J <br /> _d 0,7 c,p 0-R <br /> PHONE#2 BOS DISTRICT - LOCATION CODE - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR BIWNG PARTY f� <br /> �nN SNE <br /> BUSINESS NAME PHONE# Ecv <br /> MAILING ADDRESS Fax# <br /> CITY Cl( <br /> Q L F' r, STATE/. LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project sped@c <br /> PUBLIC HEALTH SERVICES Eimaa+ntENTTALHFxTH ONISION hourly charges associatedwith this projector activity will be billed to me or my business as identified on this famh. <br /> also certlfy that I have prepared � <br /> •'-176 firatlon and work ork to he performed•x�ll be done in accordance with a0 SAN JOAGuiN COUNTY Ordinance Codes.Standards.STATE and <br /> FEDERAL laws.APPLICANT <br /> APPLICANT SIGNATURE: 1 DATE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/NWAG ❑ OTHEi AtnHOmzED AGENT <br /> ITA is rot Re 8,1 mPu ,,proololwRla¢mfion b sign o rswved Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owneror operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentailsite assessment information to the SAN JOAOUIN COUNTY Pueuc HEALTH SERVICES ENVIRONMENTAL HEALTH DmSiON as Soon <br /> as it is available and at the same time itis provided to me or my represemative. <br /> TYPE OF SERVICE REQUESTED: ,rJL-% <br /> COMMENTS: <br /> LD A-8, -3 6r ,S?'u.b <br /> PAYNI� N <br /> RECEIVE- <br /> �y; LIAR 0 8 200? <br /> SAN'JOAQUIN <br /> PUBLIC HEALTH SEP: <br /> C ��0 ENVIRONMEPIiAI HEAL'" <br /> �. <br /> GOA\G��OR's SIGNATURE: <br /> IN ECTOR'S SIGNATU 6�d I" O <br /> APPROVED BY:: SP `- �� DATE_o 3 C2 <br /> LFeeAmount <br /> TO: I _ _ �.�C ENS\ 'EMPLOYEE#: DATE: <br /> vice Complet (if already comp ): - SERVICE CGDE: .. 'P I E. <br /> Payment Date <br /> t Type Invoice# Check# Received By: <br />