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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SER lR, �QUE ST# 9OWNEftI OPERATOR <br /> r BILLING PART <br /> FACILITY NAME ` <br /> r d' v Lk <br /> SITEADDRESS �'1'] 1 1 `y Low 'r <br /> 60cre O �(X" <br /> Strsn Numpar D4eceon StrM Nan/ Suea/ <br /> Mailing Address (If Different from Site Address) T". <br /> Cm f^V� STATE ^ ,^ zip <br /> Ow • <br /> PHONE#'I Ev. APN# LAND USE APPLICATION# <br /> 0 <br /> ( - 7 � l - O <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> BUMG we PARTY❑ <br /> BUSINESS NAME PHONE# us. <br /> 7- 370 / <br /> MAILING ADDRESS FAx# <br /> l oct fan CvT (�cP; C'19 RC1 ��0 - f 3l <br /> CRY STATE ZLP <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 EwRONMENTAL HEALTH DmsloN hourly charges associated with this project or activity 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 the work to be Performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. /� / Y Or <br /> APPLICANT SIGNATURE: l l\_i(1?a� UAJ DATE: (' —OIAI"DCI) <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/IVIANAGER ❑ OTHERAUTHOFUZED AGENT ❑ 162eOtOGII <br /> PPr.rwST <br /> 1/Arisnol Na04i cPura proof Of to sign is mquind U iirle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owneroroperatorof the property 10mled at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsroN 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 /> A,e VCV•47A w� ��1 tiPag� r--( Y' UA <br /> trtit�.�i�� <br /> 4V 0 4,60 71z, Il-L <br /> SPu IME�p�PEP NOEV SION <br /> GO <br /> ENV\PON <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED DY:1. EMPLOYEE#: DATE: <br /> ASSIGNED TO: � EMPLOYEE#: DATE: <br /> Date ServiCC Completed (if already completed): SERvIcECoDE.-5: P f E.266•"� <br /> Fee Amount: '3c��y_ Amount Paid <br /> Payment Date Z�OU <br /> Payment Type GN-r✓G� Invoice 9' Check 4I Received By: <br />