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.. <br /> SERVICE REQUEST <br /> i ,,—+ <br /> Type of Business or Property <br /> FACILITY ID# SERVICEREQUEST# <br /> iZ00 i � Z7 <br /> OWNER OPERATORBILLING PARTY C <br /> .9EG6le IKATZA914tJ <br /> FACILITY NAME <br /> SITE ADDRESS /v , IDVC <br /> — X.D. <br /> SbeN xunuty nirecnen Str N. TYD• suhei <br /> Mailing Address (If Different from Site Address) - <br /> P,o . 3vK . (2.3c) <br /> Cm t STATE "'A ZIP 9 S 2-3lo <br /> GYIi <br /> PHONE#1 eT- APN# LAND USE APPLICATION# <br /> (" 4F I _ 13(o�1 b63 - 270- �o f A - 03-16 <br /> PHONE#2 BOS DISTRICT - _. - LOCATION CODE. <br /> CONTRACTOR I SERVICE REOUESTOR <br /> REOUESTOR <br /> BIwnG PARTYI - <br /> BUSINESS NAME PHONE# - <br /> D(LI,I AAU6Pe-,r 2,A 33Y-66 /3 <br /> MAILING ADDRESS � QOX Z(,5 U F <br /> P 2oj 33Y-0-7z3 <br /> CITYLai', STATE (fA zip c',Z;:'Z_ <br /> BILLING ACKNOWLEDGEMENT: I, the undersgned property or business owner,operator or authorized agent of same, admowledge that all site and/or project spedfC <br /> PuaOc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity Yrill be billed to me or my business as identified on this farm. <br /> I also certify that I have prep app tion and that the work to be performed•left be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL taws. -- may <br /> APPUCANTSIG TORE: DATE. <br /> PROPERTY I BUSINESS OWNER C OPERAT R/MAXAGER OTHER AUTHOR=AGENT C <br /> IIAv�Lc wru ex PAmr.Proof of authodrsdw to sign is required <br /> Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the ovmer 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 environmenmilsite assessment infannabon to the SAN JOAQUIN COUNTY PUBLIC HEALTH SFRvICES EwRONMENTAL HEALTH OIVISAN 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: <br /> 100y <br /> 0C r . 12004 <br /> Sgry JOA <br /> FNW OW COLI <br /> HES HROEPgR M L <br /> INSPECTORS SIGNATUR . CONTRACTORS SIGNATURE: <br /> APPROVED BY: EdPLO'y�}f: DATE Q 6 <br /> ASSIGNED TO: C" I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: - "�;. "P/E:. 2( <br /> Fee Amount- IWO Amount Paid - Payment Date <br /> Payment Type Invoice 9 Check 9 Received By: <br />