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',..r SERVICE REQUEST <br /> Type of Bpuusiin�ness or Property FACILITY ID# SERVICE REQUEST# <br /> l !Z 7— 7 <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> PP-�s-rof� l.E�BErr� <br /> FACILITY NAME <br /> SITE ADDRESS I-ZZ kAMM014D <br /> i Stre.tNwMv OirtceOn r` str K. T,. sun ;i <br /> Mailing Address (If Different from Site Address) , <br /> o - Pac <br /> CITY STATE ZIP <br /> L�vtia <br /> PHONE#1 EST• APN O �T LA170 USE APPOCA710N# <br /> ( 17.7 — �( oL�f <br /> PHONE#2 Ea. BOS DISTRICT - - LOCATION CODE_ - <br /> 204- 130 v <br /> CONTRACTOR]SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY O <br /> M► 7 <br /> BUSINESS NAMEPHONE# <br /> D)LL-4;anl k A4ue, #y 3 �6� <br /> MAILING ADDRESS D' �� "� <br /> FAX# — DWZ7; <br /> PPix zf q <br /> Cfry �) � STATE ZIP 664 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same. acknowledge that ail site and/or project spedfc <br /> Pusuc HEALTH SERVICEs EWRCNMENTAL HEALTH ONISION houny charges associated with this project or activity will be billed to me or my business as identified an this tone. <br /> I also cerdty that I have prepared this appfication 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: ,C/ / (�/J DATE: <br /> WNZS'G� <br /> PROPERTY I BUSINESS OER C( OPERATOR]MANAGEfi ❑ OTHER AUTHORED AGENT ❑ <br /> If APPLCcff is net Me611 No PM1Y..Proof Of aUffminCen to sign c rsWued Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or apemtor of the property located at the above she address,hereby aulhoaze the release of <br /> any and all results,geotechni©I data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUMUC HEALTH SERvICES ENvIRONNF_HTAL HEALTH ONISX7N as soon <br /> as it is available and at the same time it's provided to me or my representative. - <br /> TYPE OF SERVICE REQUESTED: 4 Lt f2-FA C l -c- 9 &t,.�,s L L SFA C E— c N r r 1- f rLl f'�'7 / - -T <br /> COMMENTS: <br /> J/2 N/0S PAYMENT <br /> ////// RECEIVED <br /> 1� FEB % 5 2004 <br /> f n SA ENOIROONEN AL <br /> tMTM <br /> V <br /> rr/"�yyy,V NT <br /> HEALTH DEPARTME <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY. (f) LI L) f K-f't E:dPL=f"}f: 032/ <br /> DATE' 2•Sr(j�6 <br /> ASSIGNED TO: j-,('E.(� /NJ} EMPLOYEE#: S,'3(p to DATE: 7.51 O <br /> Date Service Completed (if already completed): SEmncECODe -. -_.�j 1,5- P I E:. <br /> Fee Amount 4 Amount Paid Payment Date <br /> Received <br /> Payment Type Invoice Check <br /> S� <br />