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SERVICE REQUEST _ <br /> Type of Business or Property FACILITY IDR SERVICE REQUEST <br /> 5 00' S" z6S <br /> OWNERI OPERATOR � � ^ BIWNG PANTY <br /> FACILITY NAME <br /> SRE ADDRESS IiO f� <br /> ' <br /> �i i $trs•c Numer oirecoan SAN'^'^ TYD• Suit•: <br /> Mailing Address (if Different from Site Address) <br /> CITY STATE C/�/ ZIP <br /> UNden <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2 BOS DISTRICT LOCATION CODE - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REgUESTOft , / � BILLING PARTY <br /> BUSINESS NAME /� . /�r /� PHONE — �/ �• <br /> MAILING ADDRESS PO C/0� �--I// /'D FAX <br /> 9 �3y���3 <br /> CITY �/)/��• OY�/ STATE C�- LPy I <br /> BILLING ACKNOWILLEDDGGEEM'ENi: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specnC <br /> PUBLIC HEALTH SERVICES EWIRGVMENTAL HEALTH DIvisioN hourly charges associated with this project Or activity will be billed to me or my business as identified an Na fomL <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JDADUIN COUNTY Ordinance Codes,Standards.STATE and <br /> FEDERAL laws. O /49j/ <br /> APPLICANT SIGNANRE: DATE: I r O <br /> PROPERTY/BUSINESS OWNER C ERATORWAPIAGER ❑ OTHER AUTHORIZE➢Acanr ❑ <br /> IIAnn..cwranatdn&L� Pura.proof ofwNormign tion N siarpuvod Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applimble,I.the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all resutm,geotechnical data and/or environmentaVsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EWIRONMENTAL HEALTH DrnsiON as Span <br /> as ills available and at the same time it's provided to me or my representative. - <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ��y/� /J��'�,�n.f.sLL��—•r r�,�� <br /> PAYMENT <br /> FIECENED <br /> SEP - 4 2009 <br /> 'SAH JOAQUIN Cl-, <br /> ENVIRONMENttd_ <br /> HEALTH OEPARIbe- <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: EIPLt7Y--#: 1✓.v - DATE <br /> ASSIGNED TO: ! EMPLOYEE#: DATE <br /> Dale Service Completed ('If already completed): SERVICECODE: 5 !Z 'P f E:. <br /> Fee Am <br /> ount• Amount Paid - ' Payment Date <br /> PaymentType Invoice# Check# - Received By: <br />