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i SERVICE REQUEST <br /> SERVICE REQUEST# <br /> FACILITY ID <br /> Type of Business or Property <br /> OWNER OPERATOR � �LVN 'e S< <br /> �FACILITY NAME p e ua S q X003 <br /> SITEADDRESS <br /> i O�j <br /> l `� NIUmber DS[eeCon <br /> Mailing Address (if Different from Site.Address} zip�� 3 <br /> STATE n <br /> CITY. ' <br /> t,a►tD t7sE APPLICATION# <br /> rsr. APN# 4 —00q <br /> L.10 <br /> 163�. ctq j <br /> SQS Dim= <br /> LOCATION CODE <br /> PHONE#2 " <br /> CONTRACTOR t SERVICE REQUESTOR 1jU-uNG PART f <br /> REQUESTOR <br /> PHONE# <br /> BustNEss NAME <br /> 01 <br /> MAILING ADDRESS cA cx-x <br /> ~�J �J7 STATE 71p <br /> CITY . <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same,arknowiedge that all site n thIsdloproject specific <br /> pvauC HEALTH$FAVIGES ENVIRONMENTAL HEALTH DNssION hourly Charges associated with this project or activitwA be billed to me or aq busines <br /> y s a5 identified an ShlS farm. <br /> TY Ordirsanca Codes,Standards,STATE and <br /> I also certify that t have prepared this application and that the work 10 be performed will be done in aocardance with all SAN JOAQUIN COUN <br /> s FEDERAL laws. <br /> APPuCANTSIGNATURE: �� yr. <br /> OPERATOR l WAGER R OTHER AUTH=LrD AGENT <br /> et <br /> PROPERTYI BUSINE55 OWNERply f of authoruagon to sign is Mulrv8 Titfe <br /> frlsewc'.�wr iS Id Use�y.�rr.__�P� . <br /> At3T1i0Rl7AT10 N 70 RELI A51 1NFORMATiON:When applicable.t,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 INEandenvironmenlallsite assessment information to the SAN JOAQUIN COUNTY PUOUC HEALTH SER=r-S ENVIR4IJMENTAL HEALTH Dmslon 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- 0 LA) li ll syo (� , <br /> t \ <br /> t �cycJl i S o Cert +r ��V� P �G ,obti����� <br /> v 5 <br /> F oHTRACTOR�,SGNATUR : <br /> IttSPE OR S SIGNATURE: �]\ <br /> APPROVED 13Y:. EMPLOYEE#: [LQ DATE: Q a <br /> ASSIGNEDEMPLOYEE#: 9 DATE: <br /> Date Service Completed (if already completed): SEizvtCEGaDE: 2Z Ef 00/. <br /> Pec Amount: � /© t� Amount Paid ('7 Payment Date t 'F/0� <br /> lnvoicc# Received B <br /> ' Payment Type ✓ Check# zl� By: <br /> E - <br />