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.�• SERVICE REQUEST ..i <br /> Type of Business or Property —7FACILITY ID# SERVICE Rt 1t ^ <br /> OWNER OPERATOR �IYn� �—' BILLING PARTY❑ <br /> FACILITY NAME <br /> SREADDRESS I Q\ <br /> SaM Numbr f)wectian ` ��/$trM Nwm Try/ SWi�/ <br /> Mailing Address (If Different from Site Address) <br /> CITY i 0 STATE ZIP <br /> PHONE 91 ET. (� APNIf LAND USE APPLICATION# <br /> ( <br /> PHONE92 ExT. BOS_DISTRICi LOCATION COOE'. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR , BILLING PARTY❑ <br /> Q J C— <br /> BUSINESSNAME PHONE# 7 _ ^ Es*• <br /> s-/ <br /> ?Z(UA MSS FAX# <br /> CITY l ,FL( M C Cti STATE LP CT Z <br /> LING ACKNOWLEDGEMENT: I, Ne 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 Omsiom hourly charges associated with this projector activity will be billed to me or my business as identified on this toren. <br /> I also certify that I have prepared this application and That the work to be performed will be done in acmnfance with all SAN JoAOuIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. - <br /> PUCAM SIGNATURE:N <br /> DATE: <br /> PROPERTY I BUSINESS OWNER ❑ �TORI MANAGER 0 OTHERAUTHGRIzEDAGENT ❑ <br /> I/APO risnotlheftm/7/nn:poofof suNwfradon to sign is npukvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1.the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and ail results,geotechnical data and/or environmentaltsile assessment information to the SAN JOAOl11N COUNTY PuBuc HEALTH SERVICES ENvwoNUENTAL HEALTH DrAsiON as soon <br /> as R Is available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: / n Ld- asp C '7 + �� <br /> COMMENTS: (/(� I F'-T0- <br /> I <br /> AAs RECEIVED <br /> FEB 2 2 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> .Date Service Completed (h already completed): SFRVICECODE: ,P I E. (xJ <br /> Fee Amount: r(N c1Amount Paid l y Payment Date (� <br /> Payment Type Invoice#' Check# 'J Received By: <br />