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SERVICE REQUEST 0 <br /> Type It Business or Property FACILITY ID# <br /> SERVICE REQUEST#LiO 41-),q"I CUI 7Zl2.4-� y 7 <br /> OWNER I OPERATOR <br /> iI��<E � urr/�t/ Mp SSDq� �}ssot/�4r .S L 7-D . BILLING PARTY <br /> RFANA <br /> tN f7�io <br /> �s La A L E,�D �� <br /> Str�atNumb�r pkKppn Str"Ham� <br /> (if Different from Site Address) Typ• Sub <br /> o x ��70 � <br /> P-cP $TATE ZIP <br /> gsr3�c7 <br /> APN# LANo USE APPLICATION# <br /> t ) -030 <br /> PHONE#2T• BOS DISTRICT ' <br /> LoCAmN CODIc, <br /> CONTRACTOR/SERVICE^R ' <br /> JEQUE570R <br /> REOUESTOR J ! /d A eArA .! It Ie, BILL]NG PARTY <br /> BUSINESS NAMEl I L IlI PHONE# OCT. <br /> MAILING ADDRESS <br /> FAX# <br />{ <br /> CITY fQ LU( -II STATE CA LP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andfor project spedfic <br /> PUBLIC HEALTH SERVICES r:wRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this Corm. <br /> I also certify that I have prepared this IiCabon and th rk 10 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br /> If Acer C.+wr islz the gum pnErry proof of authorkallon to slI is raqu Titre <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,geotechnical data and/or environmentaftte assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERvICES ENVIRONMENTAL HEALTH DN%iON as soon <br /> j as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> QFA6f AND u 9-Ca ZFA-eir aW7-,4 MrN,4 i/an/ /7?j�5Pp.2T 11i V1 "A/ <br /> COMMENTS: Il_2Do0 <br /> 4 eC6 R64AI AI RECENED <br /> JUL 18 2040 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> INSPECTORS SIGNATU CONTRACTOR'S SIGNATURE: <br /> APPROYEDBY:, EMPLOYEE#: DATE: U Y <br /> ASSIGNED T0: EMPLOYEE#: DATE: o <br /> Date Service Completed (if already completed): SERVICECODE: <br /> Fee Amount: Amount Paid /156 Payment Date —7//0, <br /> Payment Type Invoice#' Check# <'� Received By: <br /> I <br />