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` SERVICE REQUEST <br /> Type of Business or Property i FACILITY ID# <br /> SERVICE REQUEST# <br /> SRS-] 53� <br /> OWNER OPERATOR <br /> L ow'e" ( ! 6 r i Sso,-Y-, BILUNG PART`/ <br /> V <br /> FACILITY NAME <br /> h.S ' <br /> SITE ADDRESS �(j/_/"7 <br /> 11 (U(J i J�5TTStreet Number rection o� ��D <br /> I <br /> Mailing Address (If Different from Site Addressl SO4 <br /> CITY 1067 r {evne v- O (v-QLc <br /> C h-1 W 1 STATE C 1„ zip <br /> PHONE#1 APN# LAND USE APPUCATION# 7 <br /> ( [)qqr 3 -s Iq3-- 1140-0� <br /> PHONE#2 UT. BOS_:DISTRICT LOCATION CODE' <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR ( � <br /> `C' ^ BI>.uNG PARTY❑ <br /> BUSINESS NAME PHONE <br /> # <br /> MAILING ADDRESS FAX# <br /> CITY -- ( <br /> I a> <br /> r1Ya> t 7 STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site andfcr project specific <br /> PUBLIC HEALTH SERVICES ENVIRONIAENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to mo or my business as identified on OIL form. <br /> I also certify that I have prepared UIi pplication and that the work to be perf rmed will b crordance with all SAN JOAOUIN COUNTY Ord.hance Codes,Standards,STATE and <br /> FEDERAL laws" <br /> APPUCANT SIGNATURE. �� DATE:_ <br /> =22z- 0 9 <br /> PROPERTY J BUSINESS OWNER ❑ OPERATOR/N ANAGER ❑ OTHER AUTHORIZED AGENT t] <br /> ITAar uc wr is not the 62I M EAmy,proof of aurhorizldon to siert is reRuirvd T i t l o <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUoUC HEALTH SERVICES ENARCI`WENTAL 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 IS REQUESTED: r� ` <br /> J [� <br /> COMMENTS: i , <br /> .30 PAY SIM <br /> RECD <br /> SAN J0- <br /> �,(y� ti PUFL[C <br /> INSPECTOR'S SIGNATURE: COITTRACTOR'S SIGNATURE: <br /> APPROVED DY:. EMPLOYEE#: �DATE:ASSIGNED T0: EMPLOYEE#: 3! <br /> Date Service Completed (if already completed): LO <br /> SERVICE CODE: Szs PIE: O <br /> Fee Amount: (� ab ( Amount Paid 4 _ Payment Date <br /> Z( � 1 <br /> Payment Type Invoice#• Check# Received 8 . <br />