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SERVICE REQUEST -..i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2 c�c z S& <br /> OWNER OPERATOR 'TBLLUNG PARTY❑ <br /> ), <br /> ' Z5 rrt2 <br /> FACILITY NAME <br /> SITE ADDRESS Z l y I r t:5 1 e- I l e✓Ih c. <br /> Suva NwMAr ao-.al� Rut Mame TYw aaa.s <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 EAT. APN# LAND USE APPLICATION} <br /> PHONE#2 SO$DISTRICT LOCATION CODE_ <br /> V 71 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEs n BR1wG PARTY 0 <br /> c �oL��2 <br /> BUSINESS E PHONE# <br /> DA Ell Vl/-onvt �6, (z 3L--?- 3 0 3S <br /> MAILING AooREss // FAX# <br /> CITY L– L ' STATE C4 ZIP �S2y6 <br /> BILLING ACKNOWLEDGEMENT: I, the Undersigned property or business owner,operator or authorized agent of same, acknowledge that all site ardor project specfic <br /> PUBLIC HEALTH SERVICES ErMRONA4=NTAL HEALTH DrvTsim hourly charges associated with to projector actvdy will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared apyI cation an�wt the rk to he performed W be tion in accordance wdh all SAN JOAwIN CCUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. // <br /> APPLICANT SIGNATURE: DATE' <br /> PROPERTY 1 BUSINESS OWNER ❑ OPERATOR/NUVIAGER Cl OTHER AUIHORTZED AGENT ❑ <br /> It APRFW u not tie 6u ac PA ..par afwMoriudw(a sign is rpubd Tithe <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby author®the release of <br /> any and all results,geotechnical data andlor envimnmentai/siie assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SER"ACES ENmRONUEtrrA.HEALTH ON ISION as soon <br /> as d H available and at the same tirne itis provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> v 5u/^ /n f ^ <br /> 4� 7-1-- z6-,, 'KC-P°A r" PAYMEN-( <br /> Tis e 5l curl 7/ c Wc7/l 6J /tr C /ae 5 2 RECEIVE[-) <br /> y <br /> ri i, 5e'flv <br /> w /.i//l,/ 7 e, t r��" / t� GST/ well JAN 2 3 2002 <br /> S /-�,p d ,ae// � SAN JOG;i J <br /> AUUIN NTY <br /> H r �T y <br /> PUBLIC HEALTH b'ERVIC[�. <br /> �/ �CrZ(/ Z c.r/tel <br /> ;r), ENVIRONMENTAL H Uln GIVISIun >q T/ro <br /> (�o e/vL.-.•c Lv��T�l�-r' y <br /> INSPECTOR'S SIG TU r CONTRACTORS SIGNATURE: 0301 r , <br /> APPROVED aY: EmPLOYEE#: /� DATE: z d Z— <br /> ASSIGNED TO: r EmPLOYEE#: 6 DATE: <br /> Date Service Completed (if already completed): - SERVICECODE: ( 'P/E-- <br /> Fee <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> �L•� � /i 2 S �"�-,^ ��p�r�''��"y fun �� / T� <br />