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SERVICE REQUEST <br /> Type of Business or Property C5-LL'ULAR FACILITY ID# SERVICE REQUEST# <br /> Wnm�E Silt A-NIN -PwCnAt rO'W'GR MS-Ot AF'N:059-2tio-31 c� <br /> OWNER lOPERATOR SAa` j��'G�RS BILLING PARTY C) <br /> FACILITY NAME <br /> SITE ADDRESS � �� TOI►1 t K Ca RcSyt R,OR� <br /> 109-79 <br /> Str..tNumber etrrcoon strNtNeme <br /> TYFe Suite R <br /> Mailing Address (if Different from Site Address) <br /> CnY L STATE <br /> CA zIP -9 G2rF-,�:P. <br /> PHONE#� <br /> [209} 4--7a- 57&b Ext. APN# 011 21 6 -3� LAND USE APPLICATION# <br /> 1.PHONE#2 BOS D1sTRjcT LOCATi(}N CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR `f! <br /> A VM Q E , G U IZ7%S giLUNG PARTY <br /> BUSINESS NAVE c I'V I L E 1it 4(3 ) WE <br /> E �9- PHONE# Exr. <br /> l68-- 59 <br /> I41A[L1NG ADDRESSFAX# <br /> 4-Ie MA7TH EEw -Q1.?tz <br /> C[TY DI ( <br /> -24BISTATE GA ZIP 9 5-24- <br /> BILLING <br /> LLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specirc <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsiON hourly charges assodaled with this projector activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this apprKmtion and that the work to be performed will be done in accordance with 9.SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE. ��"'^'" DAME: 93/12/6 f <br /> PROPERTY I BUSINESS OWNER Q OPERATORIMMAGER OTHERAUTHORIZEDAGENT <br /> I/Arvuc+wr is nuf ft proof of aurhoeizallon to sign is mqukvd TWO <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 environmental/site assessment information to the SAN JOAQUIN COUNTY PUDLIC HEALTti SER=Es ENvirzonmE-NTAL HEALTH DmsioN as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: SAIL SU47rAB'I Lti-TY P—EvLGV*'� <br /> COMM2.7-Of IV I Til`IT / S 4 J <br /> �� TENDS Yb1-116H <br /> THiS l3 RFfJ nl��j`vef PAYMENT <br /> ,BE hFi6 y ,N Nrrfl�,9 et5 ( RECEIVED <br /> SEP ? 210 <br /> SAN JQAQUIN COt1NTY <br /> EALTHSERVICES <br /> ENVIRONVfFP <br /> jAL HEALTH GIVJSfO <br /> N <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE: 1 17 ro <br /> ASSIGNED T0: `� EMPLOYEE#: D <br /> I f .. l] I f— <br /> �1 <br /> Date Service Completed (if already completed): SERtnCE CODE: <br /> a PIE:. <br /> Fee Amount: Amount Paid DU Payment Date '3 h;?- l <br /> Iv <br /> Payment Type Invoice#' Check rf '1 <br /> `1�� Received By: � , <br />