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SERVICE REQUEST <br /> Typ of Business or Property FACILITY ID# ...,. SERVICE REQUEST # <br /> t le ca-?z<2.�4 <br /> OWNER/ OPERATO�R'7� <br /> —��� CHECK if BILLING ADDRESS <br /> FACILIIY E <br /> SITE ADDRESS l <br /> _-_5Irgg1 Number _Qlrectlgn _ �jrggj NaTPqType aIle a <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> _-73 34 O© 5 <br /> CITY STATE ZIP <br /> PHONE#1 Ex r. APN# LAND USE APPLICATION# <br /> LT EXT, BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME J PHONE# EXT. <br /> 0-0 N Zc*t> Y-.7 7 �9¢y <br /> HOME or MAILING ADDRESS FAx# <br /> 12A 4-9 <br /> CITY _ STATE CA <br /> Zip �S'3s / <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC If'EALm SERvicES ENVIRONMENT-AL I-IFALTII 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 with all SAN JOAQUIN <br /> (,1)UNTY Ordinance Cordes,StandardAST,k - FET)-- I aws. <br /> APPLICANT'S SIGNATURE: DATE: TJ17-4 <br /> PROPERTY/ RITSINESS OWNER OPERATOR/MANAGER O R:\UTTfORIZED T <br /> IfAPPLICANT is not the BILLING P IRTY proof of authort r is regairerl Trrlr <br /> AUTIIORIZATION TO RELEASE INFORMATION: When 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 an�Vor environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY Pt111LIC HEALTII Sf•.RvICT:S ENVIRONN111:NFAI. IIEALTII DIVISION as soon as It is available and <br /> at The same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Lam" dal <br /> COMMFNIS: <br /> AUG 2 41Ow <br /> 7 <br /> tNVIYRONMENTALT EALTM IOlVWICl , <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> _ _ - <br /> _ Er.1PLOYEE#: DATE: Q <br /> APPROVED BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> Date Service Completed (if already c mpleted): <br /> SERVICE CODE: 5� P 1 E: D/ <br /> Fqe Amount: <br /> / Amount Paid ��� Payment Date �(� <br /> Check # G Re eiverl' y:��— <br /> P)yment Type I Receipt # / 3 �' <br /> ',,1/1999 <br /> SItRF()rev doc <br />