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NOW <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10 R SERVICE REQUEST m <br /> LOMMEeC144, <br /> OW NER I OPERATOR BILLING PARTY <br /> Lo We LL PA <br /> FACILITY NAME <br /> SITEADDRESS - 77, 5 � Lr gGa-rY p� � <br /> L� Stre.t Numbr Oirtctian Suertxma ry,. SUReY <br /> Mailing Address (If Different from Site Address) <br /> @ . O 7Z <br /> ST ZIP ZZ-7 <br /> Cm G(�M� T <br /> PHONE#t APN 3 LAND USE U TION 4 <br /> eol 7S4I -3oo7 071- 7100 —ZZ— V�( <br /> PHONE#2 ErT. BOS DISTRICT // _ - LOCATION COOE.r - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY,T <br /> C <br /> BUSINESS NAME `+ L L ti r h^ up—P# <br /> PHONE# -331-1 & 613 6 1 3 �T <br /> MAIUNG ADDRESS ll L I V I (/rT FAX r# �J'�Z <br /> ? 0 r3 oy bo 3 ti <br /> Cm - STATEC- A- ZJP gSZ4 <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 /> PUBLIC HEALTH SERVICES EwrtcNMEHTAI HEALTH OTvisroN hourly charges associated with this project oraclivity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that Ne-:ark to be performed will be done in accordance with as SAN JGACuim COUNTY Ordinance Codes,Slandamrs,STATE and <br /> FEDERAL laws. -� /� DATE: / <br /> APPLICANT SIGNATURE: `� 1 <br /> PROPERTY/BUSINESS OWNER C OPERATOR I MANAGER OTHER AUTHORED AGENT ❑ <br /> IfAPP WisXtde Br�PIFlY.proof ofwtboriadw to sign brsquued rills <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner 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 emimnmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Dms$ON as Soon <br /> as it is available and at the same time it <br /> is provided to me or my represamative. - /'') .yam <br /> TYPE OF SERVICE REQUESTED: J(-)aF e:: �,. SOS (AIZ-F"6 NA" I / -rl,) / //.'� POO / <br /> COMMENTS: �J r''RR-� (J�/ Y ���"rr ll r'I '1A r7r I_ <br /> � 1 ,t17,r + ✓gVFM A/ <br /> �%G" <br /> �vv,oq 4 2004 <br /> yFq�N��ROIy/N 00� <br /> �OFpgR/vT,gyA'fY <br /> MFNr <br /> INSPECTOR'S SIGNATURE. CONRNCrOR'S SIGNATURE: <br /> APPROVED BY: 7YEaE 9ATF O 1. <br /> ASsIGNEDTO: - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): - SERVICE CODE: <br /> Fee Amount r Amount Paid Payment Date <br /> Check 9 Received By: <br /> Payment Type _ Invoice a r <br />