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SERVICE REQUEST !, <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> ,r-5/ P ENT/A4 1A f,/ZfeaL <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> S E2T PO rrl r3D <br /> FACILITY NAME <br /> SITE ADDRESS Vj Al ASV CccSC) �D <br /> �Q sbnr Numbr o4ucdon S.arNamr TYPE SuiUr <br /> Mailing Address (If Different from Site Address) <br /> STATE /.^ ZIPL?76 <br /> CITY �R4C Cf'1 <br /> PHONE#1 �T APN# LAND USE APPLICATION# <br /> ( ) a3 q -deo-ra 1 n/o T1s I:r YE7 <br /> PHONE#2 Eff• BOS 0171cr _ I-cuTIDN CODE.- - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR Su-wG PARTY IV <br /> D o,v c�1�SN� <br /> BUSINESS NAME PHONE# ezr. <br /> (� (a(8- <br /> MAIUNG ADDRESS FAX# <br /> P. 45ox 7114 lo �� -2s 98 <br /> CRY —u Z LO STATE f ^ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge Nat all site andlor project specific <br /> PUaOC HEALTH SERVICES ENVIRONuENTAL HEALTH OMSION hoUny charges awo=ted with Nh projector advnly will oebilled to me or my business as identifleW on N5 fomL <br /> I also certify that I have prepared N p liadon and a worts to be performed will be done lo accordance with all SAN JGAGUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. Z <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER 0 OPERATOR I MANAGER ❑ OTHFAAUTHORRFDAGENT j,4/ <br /> d APltvWr it de 11r prm pwl ofwdwt idw M sipsa r ..d Till. <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I.the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geoterhnial data andlor emrimnmentallsite assessment intonation to the SAN JOAQUIN COUNTY PUeuC HEALTH SERvicES EwRONMENTAL HEALTH ONLs1ON as soon <br /> m it is availabie and at the same Rn1e it is provided to me or my repiweralive. <br /> TYPE OF SERVICE REQUESTED: <br /> L �, ✓ E <br /> COMMENTS: e�/. r.d:> a.--4 Jrjlj ? 7o'4S re�Lt C,oe ! f7'�.)"v� lirlt ~Lft-V r(LPI.RC— <br /> INSPECTOR'S SIGNATURE: j _ CONrRACrOR'S SIGNATURE: i If <br /> APPROVED BY: �/ �a\1 E71PLoYEEA: 7 DATE: I f ht <br /> ASSIGNED TO: Lw /v EMPLOYEE A: DATE: <br /> Date Service Completed [if already completed): SFRVICECODE: ,2 .b 'P I Ec <br /> Fee Amount v eYii Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> jc <br />