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I • • /J <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ifesideel ><fal 3_S" <br /> OWNER I OPERATOR <br /> &Lune PAR <br /> FACILITY NAME <br /> SrTEAoDRESS / <br /> //O/9 r=' Peer SuWN=bw Direction / ���sG..T,m ` • TYP. Snit.I <br /> Mailing Address (If Different from Site Address) <br /> FOB /o ZZ <br /> CITY . STA LP <br /> O cZ <br /> LacKe r 37 <br /> PHONE#1 tw.=AP # LAND USE APPLICATION# <br /> ( ) —370 /yi59 —/q <br /> PHONE#2 EXT. BIDS:DISTRICT T •'.�•'�: LOCATIONCODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR SLUNG PARTY❑ <br /> �Ctrnesf � shyeTy, <br /> BUSINESS NAME PHONE# - UT. <br /> Gva� �/�• 3 -l3 75 <br /> MAILING ADDRESS FAx <br /> 33SS -p/�,— shah Rd, ��3/- 2373 <br /> CITY .J f'b do JLVV) STATE LP 9.S2— <br /> IS— <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 activity will be billed to me or my business as identified on this(orm. <br /> I also certify that I have prepared this application and that the work to performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL IaWS. <br /> APPLICANT SIGNATURE: � � <br /> DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT \i' Z—Ly(L i5—rt/`6fL <br /> IIAPPtxswris ad Ne BniwGpu .proolol authorusdon to sign is rvquirvd/\ Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owneror opemtorof the property located at the above site address,hereby authodze the release of <br /> any and all results,geotechnical data and/or environmentallsile assessment Information to the SAN JOAcuIN 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: p t r <br /> )'t E'l//'e-LA) <br /> COMMENTS: r{ P /til 6,�`,yI r Q� di �i Y-0- <br /> 1,o,- <br /> -A" '�`2 G'� LSO Z vS% ✓r✓C/ <br /> I �lY 9 C� Y PAYMENT <br /> 5 A-; y� 1t/ c� (.IJaS'r0 f p � • T S/� C�l Cl ��� RECEIVED <br /> JUN 0 4 2001 <br /> SAN.JOAO'_'!N.;OUNTY <br /> PU61.I1,HrAIIH SERVICES <br /> FNVIRUMJEN�AI. 1fi:P.l.`H DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: 7(aD / DATE: <br /> ASSIGNED-TO:O: �,LQ EMPLOYEE#: w ` DATE: <br /> Date Service Completed (if already completed): ,> SERVICE CODE_ C3 P=E: <br /> Fee Amount: (ITC) Amount Paid C' Payment Date SCJ <br /> Payment Type t Invoice g' check# h 1 Received By: �j <br />