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SERVICE REQUEST ..... <br /> Type of Business or Property FACILrrY 1014 SERVICE REQUEST» <br /> ZFS0 7 <br /> OWNERI OPERATOR BILLING PARTY❑ <br /> L(=—Is p�1 R �S CTRL <br /> FACILITY NAME <br /> SITE ADDRESS F r( <br /> 11601 1 It I INvnOr arF.ann �a (�Ir2rt so,.a,�o. sus.. <br /> Mailing Address (If Different from Site Address) <br /> Fa, <br /> Crry STATE y� <br /> �TaGIC-S'CS aJ - c 952to1 <br /> PHONE#T rA,• APNA LAND USEAPPLICATIONw <br /> (z.l %1 1 - 1 n\e>,om sus;D . <br /> PHONE#2 EaT- BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQuESTOR --.�GF <br /> BILLING PARTY❑ <br /> LG E3 xaaca�l Q a'....vC�18S ETAL <br /> BUSINESS NAPE PRONE iF [sr <br /> MALLING AOOREss FAX 9 <br /> 115p. 1Zab,v��loW ps2. S c \-C <br /> CITY5 v r tic <br /> "�+J STATE <—p,— Z8 9Szo� <br /> BILLING ACKNOWLEDGEMENT: 1, the unaersigned property a business am",operator or authariwd agent of same, adawaAAdge that as site andlor projorl speak <br /> Pueuc HEALTH SERvK.Es ENmcow aa&HEALTH Oms*N hourly dharges assodzted with Ito project oradfvdy wIB be Wed 0 ma or my business as identified an Nc bar, <br /> 1 also Cordy that I Dave propared this apprration and that Ne work to be pedamled wit bo done in aoaardanca with all SAN Xuxm COUNI Ordinance Codas.SlarMarda,STATE and <br /> FEDERAL laws. ,/0 <br /> APPLICANT SIGNATURE:_ (/✓/A —/-! DATE '%\\.��cl <br /> PROPERTY I BUSWESS O / ❑ /QPQLATOLI/MiNK.ER 11 OTHER <br /> aAPPr Tisn flwg.rrr:F!.g.r prodafaudwh2tion tosgo is ra9urod z TfUe <br /> AUTHORIZATION TO RELEASE INFORMATION:YBIm appicable.L the awrwor operator at Na <br /> property bcatod at Ne above Sita address,hereby audrM>e tlIe release of <br /> any and all results,geotech=l data anllor anviwLnlaltaYsda assessment inl rmation b Na SAN JOwIm CORM PUBLIC NEAUH SERvIcEs EnvworurExuL HEALTH OMSTGN as saar7 <br /> as it Is available and at the same time R is providedtome or my rapn� tentithe //� <br /> TYPE OF 5ERVICE REQUESTED: 1-4 . <br /> COMMENTS: <br /> PAYMENT <br /> / � 2r ✓ Uva � � 5� �� �. �1Lp�l � RECEIVED <br /> T/e rr I. 7 21c�m �Ol/ rI�TIVo tlzp case � NOV x. 42001 <br /> ynn `l�J SAN JOAQUIN COUNTY <br /> / ✓ a O .�STi�- � r f Ur I,O. RONMFNEALPUBLIC HT FALTH IDM <br /> INSPECTOR'S SIGNATURE: jCONTRACTOR'S SIGNATURE. <br /> APPROvEO ay: E�IPI,OYE:.p; �/ DATE: <br /> A.s=NEDTO: ' 2 EMPLOYEE a✓`: O/ GATE: <br /> Date Service Completed{d already completed): I �u IP SOMMCaoE: 3/5- PIE-26Q 3 <br /> F <br /> Amount P 'o AmountPaid Payment date <br /> ment Type Invoice Q Check 1i Received By: <br /> i <br />