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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G 00;1- 5 3 <br /> OWNER OPERATOR BILLING PARTY❑ <br /> A j5—�5l A ma l,;:A rzT 15 R r rP <br /> FAciL rY NAME vka] , <br /> S ITE ADDRESS ; <br /> oZ ?7 str.yNu m W� /Vk A r' 1?7rFL 172 swm.r <br /> Malling Address (If Different from Site Address) <br /> CITY STATEZIP r <br /> 2AC �Ar j 76 <br /> PHONE#1 T• APN# LAND USE A,,PP}P�CAn0N# <br /> .PHONE#2 BOS;DISTRtcr LocATIONCOoE'. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REgUESTOR BUMG PARTY <br /> BuslNEss WE V PHONE# UT.ALL ,9 <br /> MAILING ADORES$ r � � FAX# <br /> 0 , <br /> CITY —f-99 2-0 C—v-- STATE 64 <br /> ZIP 9-5-39 9 % <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acirnowtedge that all site and/or project speck <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Dr AsioN hourly charges associated with This project or activity%in be billed tome or my business as iden0ed on this form. <br /> 1 also certify that I have prepared plication and a work to be performed will be done in accordance with an SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANTSIGNATURE: DATE:—./Z— <br /> PROPERTYIBUSINESSOWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> [fAPmr.mrhrdftkUMurry pmol of authorization to slpo Is Mutrvdd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,l•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 environmentaUsite assessment infommaUon to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EwiRoNMENTAL HEALTH Drosion as soon <br /> as it is available and at the same time itis provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMLNTS: <br /> PAYMENT <br /> RECEIVED ' 1! <br /> .IAN 3 1 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> tNSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:, L EMPLOYEE M { DATE: <br /> ASSIGNEDTO: EMPLOYEE#: 7 �\ DATE: <br /> Date Service Completed (if already completed): I SExvscECODE; '3 ��i ..PIE: (Q3 <br /> Fee Amount: Amount Paid 1 C b Payment Date ! ,Q <br /> Payment Type Invoice#' Check# <br /> A10Av-&1-4.A9L6 (089) <br /> — lzUMrrv��t� 30�7 8 <br />