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SERVICE REQUEST 's <br /> Type of Business or Property I FACILITY 10 k v SERVICE REQUEST <br /> -1-12U6 0 qC) g <br /> OWNER I OPERATOR BILLING PARTY <br /> `F4/_ r 0lAle <br /> FACILtiY NAME <br /> SITE ADDRESS <br /> �7 c/� S �12 A �0 <br /> /0 lc - �• Sow sumer WracVon MrtMama TYoa su,lat <br /> Mailing Address (if Different from Site Address) <br /> CITY _ STATE ZIP <br /> F2ENG1-/ GL{/7f (!��4 <br /> PRONE X1 APN S LAND USE APPLICATION# <br /> ( S -IL <br /> PHONE 92 BOS DISTRICT - LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQIIFSTOR BILLING PARTY <br /> Vo11 <br /> BUSINESSf�AME _ _ ___ PNONEX <br /> V yGE. _Ac Zv9 -/k3 <br /> MAILING ADDRESS FAx It <br /> D • SO �7`t4 (t-0q) (06 Zs 8 <br /> CITY 72 Q STATE ,.^ LP <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property or business owner, operator or authorrsed agent of same, atlmowledge Nat all site and/or project spe lic <br /> PUBLIC HEALTH SERVICES EtrvIRGNMENTAL HEALTH ONISION hourly charges associated with anis project or activity will be Dined to me or my business as Identified on this ton. <br /> I also ceroty that I have prepared this application an"I the work to be performed will be done in aanrdanca with at SAN 3DAGUm COLRM Ordinance Codes. Standards, STATE and <br /> FEDERAL laws. <br /> DATE: <br /> 4-2, Q <br /> APPLICANT SIGNATURE: <br /> PROPERTY I BUSINESS OWNER 1s *EnArDIRI EROTHEAAUMCRIZED AGENT <br /> CAPalcwris not teB ,Mpyrr.P'.1 of wthomradon balm is rpufrad idle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I.me owner or operator of the property located at me above site address.hereby authorize the release at <br /> any and all results,geotechnical data and/or enveOnmematsite assessment Into matron to the SAN JOAQUIN COUNTY PUBLIC HEALJN SERVICES ENVIRONMENTAL HElLTY.OrASION as Sao.'i <br /> as it is available and at the Same time it is provided(a me or my./ representative. -�!� <br /> TYPE Of SERVICE REQUESTED: / rk A,T� / AI)�,�LZ --S/u O <br /> COMMENTS: ,`r <br /> APR 3 0 I9' <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: c q <br /> APPROVED BY: I I EMPLOYEE t C W \ DATE: -3 d [ l <br /> ASSIGNED TO: ` EMPLOYEE n: I DATE: <br /> Date Service Completed (If already completed): ERYICE CODE: PIE:�_(p0 <br /> A <br /> Fee Amount <br /> Amou Paid I Payment Date <br /> Payment Type I Invoice I Check x Received 8y: <br />