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SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> 8-OWNR es;d eY►c t /E- <br /> OWNER I <br /> ER!OPERATOR BILLING Pax <br /> Fran Na OM UrVtG arks <br /> FACiLrry NAME <br /> SITEADDRESS LOC U S/ 7—rCc— <br /> 3 Stmt1lumber 01redon street Name TT7YP. SUHet <br /> Mailing Address (If Different from Site Address) <br /> Sa Pk C <br /> CITY STATE zip <br /> b G/� gf gS2 q-0 � <br /> PHONE#1 T• APN# LAND USE APPucAT1oH# <br /> PHONE#2 BQS DISTRICT LOCATION.CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR _ BILLING PANTY❑ <br /> 6a r vt� �_ S-�L . <br /> BUSINESS NAME PHONE# sxr. <br /> MAILING ADDRESS <br /> s 3 ss <br /> -57b 14 rr1 �wGo{ , FAX# q3/- 3 7 <br /> CITY S f0 G STATE e'lof ZIP <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 /> PuBuc HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: �!!� � _ DATE: Z dG I <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT xr C(�rL Fj <br /> II APPLr-Amr is not ft Bum PARrr proof of authori arlon ro sign Is required Titre <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 environmentallsite assessment information to the SAN JOAQUIN COUNTY PueuC HEALTH SERVICES EtMoNmENTAL 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: <br /> EQUESTED:COMMENTS: l <br /> D , <br /> S APR z ?d®t <br /> PULS JOpOUIN COLIN <br /> Fl�VlRpUj �RLtIIEA TR EV TY <br /> S <br /> INSPECTOR'S SIGNATURE: CONTRACTOR`S SIGNATURE: <br /> APPROVED BY:. EMPLOYE:#: DATE: <br /> L111 k) <br /> A55iGNED 70: G/ EMPLOYEE#: DATE: <br /> r <br /> Date Service Completed (if already.completed): rn� <br /> SERVICE CODE: - P!E:. <br /> Fee Amount: � <br /> Amount Paid �^ Payment Date <br /> Payment Type ✓ Invoice#' Check# 3 3 Received By: t <br />