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SERVICE REQUEST �. <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M/r1E2L'/R L T2U6K/Nl <br /> OWNER/OPERATOR _ BILLING PARTY❑ <br /> 1/ SP M k /N� /1J I /L L SCA/!I/E2 ;E' <br /> FACILITY NAME <br /> P x/ <br /> SITE ADDRESS yv/q Q 2 u <br /> Street Number Direction / L7 A mrmlxa Trpe Suae1 <br /> Mailing Address (if Different from Site Address) <br /> CITY 7- e 0 P <br /> a STATE C,4 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR <br /> N _ ESNE BIuwG PARTY <br /> BUSINESS NAMEPHONE# <br /> e / /���E^�� <br /> V L- C JLTL /Y <br /> L Exr. <br /> MAILING ADDRESS FAx# <br /> CITY �7 ,n STATE SA <br /> /-)t zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION hourty charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this 1' tion anNthatpd-ijbkto be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. / c <br /> APPLICANT SIGNATURE: DATE: C O a U <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHERAUHowmo AGENT <br /> YAPPccavrisnot Bre BuwGPAnry poor ofsu"zadon to signs required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property baled at the above site address,hereby authonze the release of <br /> any and all results,geotechnical data and/or environmentallske assessment informabon to the SAN JOAOUIN COUNTY PUSUc HEALTH SERVICES EHVIRONMENTAL HEALTH DNISION as soon <br /> as its available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> 41!L 56eT 3/c c TU D Ny772 TF_ Go AD/r✓< <br /> COMMENTS: <br /> y 0 •Zq •q�j //� P#Ov�9/Ii'EIV 6 <br /> rE;FIVE' <br /> OCT 2 01999 <br /> LIBLIC[AN HEALTH coir..r <br /> ES <br /> ENVIRO MEN AL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: rZl.�.-0 DATE: O — <br /> ASSIGNED TO: EMPLOYEE#:Fff atu 3 DATE: <br /> Date Service Comple (if already completed): '/_ rf SERVICE CODE:S z PIE. 021- <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice#' Check 9 Received By: <br />