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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IRou <br /> OWNER OPERATOR BIWN PARTY❑ <br /> —10 5c So A e. <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 5 3 Layn. K <br /> Mailing Address (If Different from Site Address) <br /> CITY / a STATE p <br /> PHONE#1/// Ev. APN# LAND USE APPLICATION# <br /> (2,A) 133S-Z-13 <br /> PHONE#2 E%i. BOS DISTRICT LOCATIOHCODE <br /> CONTRACTOR/SERVICE REOUESTOR <br /> REQUESTOR BUIJNG PARTY❑ <br /> BUSINESS NAME PHONE# Fzr. <br /> MAIl1NG ADDRESS I <br /> Cm STATE LP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUDUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project oractivity will be billed to me or my business as identified on IhLs form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Slandards,STATE and <br /> FEDERAL laws, \�� � <br /> APPLICANT SIG^"' ^' DATE: ill) --LO -coo <br /> PROPERttIBUSINESS OvvNER ❑ OPERATOR/MANAG ❑ OTHERAUTHORIIED AGENT ❑ <br /> IIAPPUc.wris rai ft QuMPrxry prtwfofauthorhadon to sign is rvguirvd Tills <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property 10mled at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or enviroflmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 /> COMMENTS: paoOr�6D TO AW 4'o AE L <br /> tR6f{ltaRING UtSa�rwG PAYMENT <br /> RECEIVED <br /> OCT 2 0 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> f� �� ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'AaY:. <br /> 1�`.(J-Z CONTRACTOR'S SIGNATURE: <br /> EAsSIGNED <br /> EMPLOYEE#: 0-7 DATE: �0 2V (r/ <br /> �/� �t M LOYEE#: DATE: '0 �1 v�"jV <br /> Dale Service Completed (if already completed): SERVICE CODE_ V vPIIEJ/� <br /> ��^ —ZCCO - ".. <br /> Fee Amount: Amount Paidt ) payment Date <br /> �, 3o C✓J <br /> Payment Type �� Invoice 9 Check# 4 Received By: ,,;,L_ <br />