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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 11 SEFFdRE UE <br /> EE, <br /> OWNER/ OPERATOR /�A/ . CHECK I1 BILL GAooRESS❑ <br /> FAautY NAME <br /> SITE AD ES I�M \ ,�f(�^-I(,` (y,��/ ' <br /> 6 �r9SLV9L45f_Vl[4it 4n Y ' ` vyJigf�LR19 I Type <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 EAT. APN # LAND Use APPLICATION# <br /> PHONE 92 Ex . BO$ DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR - CHECK If BILLING ADDRESS <br /> W <br /> BUSINESS NAME _ PHONE Exr <br /> HOME or I NG ADDRESS FAx# <br /> r' ( ) <br /> CITY STATE ZIP <br /> (711 1 ING ACICNOWLEDGEMEN'I': I, the undersigned property or business owner, operator or authorized agent of sante, <br /> acknowledge that all site and/or project specific PUBLIC IIEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> 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 Willi all SAN JOAQUIN <br /> COUN'T'Y Ordinance Codes,Standards, STATE and FCDFKAAL laws. e� <br /> APPLICANT'S SIGNATURE: ////( //`/' DATE: <br /> PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTHERAUTBORIZED AGENT <br /> If APPLICINT is not[lie 13ILLING PARTY. proof of authorization to sign is required Till, <br /> AUTIIORI7 \TION TO REI EASE INFORMATION: Wlhcn applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirnmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES ENVIRONMENTAL. FIEALTII DIVISION as soon as it is available and <br /> at du same time it is provided to me or my representative. <br /> TYPE OF SERVICE REOUESTED: <br /> COMMENTS: `T�`A1�NT <br /> ,0 -� �Ai� , 0 <br /> CT <br /> 1 p.y/-f9 eN�aop�chiol <br /> FNrgL y)Ysi Opvri, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: �L CFS <br /> EMPLOYEE#:"� 1 DATE: N <br /> APPROVED 6Y: O U <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complotod (if already completed): 0..7SERVICE CODE: P I E: <br /> Foo.Amount: <br /> S O Amount Paid �) J Payment Date /0// /6/1?� `� <br /> Payment Type Receipt # Check # �7J� Received By: <br /> SRIU-Qw doe 7/1/1979 <br />