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SERVICE REQUEST <br /> ..r <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CwU,(LI-(y l O / (0 y8' '/ <br /> OWNER I OPERATOR BILLING PARTY G <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Cal Street Numeer Direction Sheet Name type Suite# <br /> Mailing Address (If Different from Site Address) <br /> Y, O. oa N <br /> CITY STATE Zip <br /> La�'aoajoVU L! ea 4 s z5'Ps <br /> PHONE#1 W. APN# LAND USE APPLICATION# <br /> ") 56t.- G I ol3 - z3o - z-7 cup- gZ - O9 <br /> PHONE#2 EST. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUES�TOR BILLING PARTY <br /> 1LSJ'. ISA L_.Ls <br /> BUSINESS NAME PHONE# ETT. <br /> MAILING ADDRESS FAX# <br /> " `?..o->• t'j (2-0N364 - aaY <br /> CfrYrl t d TATE ZIPS LS <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 ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project Or acts ity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FECERAL laws. C <br /> APPUCANTSIGNATURE � ' DATE: <br /> PROPERTY I BUSINESS OWNER G OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br /> vAPPu risrlOr Che BaLWPAPTY.Proof ofauthorizadon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,Tel authorize the release of <br /> any and all results.geotechnical data and/or environmentallsits 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: ,, `` I p�D <br /> I�+ (�r44L Ltr.yRAil <br /> p� <br /> COMMENTS: / / oo 0 � REC,E �/8F—D' <br /> [/oo .f v u PPolo/e, AUG - 41998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISI N <br /> INSPECTORS SIGNATURE: CONTRACTOR 5 SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: LTP.TEI <br /> ASSIGNED TO: EMPLOYEE#: O DATE: C?1 <br /> Date Service Completed (if already completed): SERVICE CODE: 5 P I E: <br /> Fee Amount: Amount Paid I Payment Date <br /> Payment Type Invoice# Check# Received By: <br />