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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST R <br /> S SS � 35 <br /> OWNER OPERATOR -y / 2 BILLING PARTY <br /> FO <br /> FACILITY NAME 1`//� '/, 6th, <br /> SITE ADORESs / 7,5/1/ N J�}G,� �iYIB Qa. R <br /> 77 <br /> smwNve,ev el,Kppe $trM Num T Suil13 <br /> Mailing Address (If Different from Site Address) <br /> CITY Lo �/I STATE ZIP <br /> PHONE#1 (� Ezr. APNI LANo USE APPUCArcN# <br /> c57c� 39�-6s/2b D63^270-`� /�.0 -If6-6dL� Ks <br /> PHONE#2 BIDS DISTRICT LGcarroN E@G <br /> CONTRACTOR I SERVICE REQUESTOR 7 <br /> REQUESTOR BILLING PARTY❑ <br /> BusiNEss NAME PH NE W. <br /> MAILING ADDRESS /,--7O O� /�O Fix g3 -O7a3 <br /> CRYZAII STATE /� ZIP f!!Cn41/ <br /> BILLING ACKNOWLEDGEMENT: I, the undergned property or business ovmer,operator or authorized agent of same, acknowledge that all site andlor project specfic <br /> Pusuc HEALTH SERvICES EWIRCNMFNTAL HEALTH DIVISION hourly charges associated with this project or activity will be belled to me or my business as identified on this form. <br /> I also certify that I have prepared this application and tha(TOR/WMWVAGER <br /> rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> _FEDERAL laws. 8 OL <br /> APPLICANT SIGNATURE: OATSW---*, <br /> / ` 7J <br /> PROPERTY I BUSINESS OWNER ❑ OP ❑ OTHER AuTmR�D AG&C W J <br /> NtAPw.c.Wr u not the Bu*c Pu ,pool ofwthamtion to sign is mqubvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I.the owner or operator of the property k=ted at the above site address,hereby authorize the release of <br /> any and all results.geotechnical data and(or envimnmentallske assessment information to the SAN JOAQUIN COUNTY PUSUC HEALTH SER"cr<s ENVIRQNMENTAL HEALTH ONIS;ON as soon <br /> as it is available and at the same time it's provided to me or my repmsemative. <br /> TYPE OF SERVICE REQUESTED: <br /> M','S ti l C. S u l >�tt t cJ <br /> COMMENTS: jj w/f� X 2l ro <br /> 2cPPO27 W/aJ� �� p4Y <br /> AUG <br /> 'JOA4 2008 <br /> yY fN� Q IN COU <br /> T H Df PAR fNT <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: ©�'I VL[ L E1PL.YEEE#. DATE. e ILI <br /> ASSIGNED TO: T rm EMPLOYEE#-. c�rDATE: !l j�- <br /> Date Service Completed (if already completed): ERVICE CGDE: . :52>Z 'P l E:.2�L r <br /> Fee Amount -2f 0, U-0 Amount Paid l C , p Payment DateCt IfC)'r' <br /> Payment Type L-' _ glot b. nvoice0 Check# 3 L{ SS Received By: Wr— <br /> C� -0-P+'.. �9 14. Co <br />