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1%es SERVICE REQUEST EH0061SR revised 09/00/98 <br /> Type of Or Property FACILITY ID# SERVICEzRE U # <br /> OWNER/OPERATORru P () <br /> �( VV\ Bal.wG PARTY,❑ <br /> FACILITY NAME l <br /> SfrM rn` V-Q-V^ 614 <br /> SITE ADOR$�atV-7Numr ��,1li1l <br /> ` <br /> G on StraetV oma Type SuileM <br /> Mailing Address (if Different from Site Address) <br /> CITY L j— STATE zip <br /> PHONE#1 p XT. APN# LAND USE APPLICATION# <br /> PHONE#Z E" BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR •( f--ft, vv� l/ln 'Pn c . 9 1 I - BILLING PARTY <br /> BUSINESS NAME U V ,` ` I '9 '_ - I �-1k 1O• ❑ <br /> �. <br /> MAILING ADDRESS : PHONE# - EXT. <br /> [.-L 110-77.. .�� ���y� 6W '# <br /> CITY -Ox , 2-D S� OP <br /> STATE C i4. LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project Of activity will be billed to <br /> me or my business as identified on this form. <br /> also certify that I have prepared this applic�Ebin,arid tt the work to be perform 'll ne in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards A E an €Rn �w <br /> L/ <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ CPERAT /MANAGER ❑ GTHERA DAGENT ❑ <br /> IIAP is not the BauNG PARTY, roof of autho ' on to sign is required Title <br /> AUTHORIZATION TO RELEASE INFOR TION:When applicable, I, the owner r operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY <br /> PUBuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS ❑ SPECIAL CONDmON(S)OF APPROVAL❑ OTHER ❑ <br /> T 5 1998 <br /> INSPECTORS SIGNATURE: '.- CONTRACTOR'S SIGNATURE: '.. DATE: <br /> APPROVED BY: EMPLOYEE#' bo DATE: lO <br /> ASSIGNED TO: O �� EMPLOYEE L DATE: 0 <br /> Date Service Completed (if alread4 comp ted): SERVICE CODE: P 1 E: L U 1 <br /> Fee Amount: 7 i Amount Paid Payment Date <br /> Payment Type I Invoice# Check# Pecelved By: <br />