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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> 50 036711 <br /> OWNER OPERATOR _ BILLING PARTY❑ <br /> I g:R 2-Y T/iliD i r/ <br /> FACILITY NAME T 4 7— QU491,46 <br /> SITE ADDRESS 396 N. H16#AVAy 99 <br /> Str Nem ei'wi.. 50- Name Type Suns. <br /> Mailing Address (If Different from Site Address) <br /> CITY .,,.c�.�� / ,/ ; STATEnA ZIP <br /> PHONE#'I •7TD`-'�r Vrv� APN'# LAND USE APCPucAATION# C//� <br /> (709 X131 - �oGYJO 05�j- 616 -03 0 - �47s`Z� 043 l7 tz <br /> PHONE#2 CIT BOS DISTRICT _ - LOCATION CODE_ - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILUNG PARTY <br /> BUSINESS NAMEP`C-" �v��,/,� PZN# 3�-66 <br /> MAIUNG ADDRESS /7 FAX# <br /> F• o. aox L150 xu 3? - 0-723 <br /> CITY L,6D)' STATE /'A ZJP c' SZd I <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business ovmer,operator or authorized agent of same,/acknowledge that all site and/or protect specfic <br /> Puauc HEALTH SERVICES ENVIRCNMENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed to me or my business as identified on this tarn. <br /> I also certify that I have prepared this application and that the ,,rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards.STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE' (/// DATE" <br /> PROPERTY I BUSINESS OPERATOR/4rGER ❑ OTHER AUniORIZEO AGENT ❑ <br /> ItAPPLc iS #rfa Bunt P.vrry proof of audmrmdon m sign n rpoued Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applimble.I.the Omer or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geoteolmifal data and/or emmmnmentaVStte assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon <br /> as it is available and at Ne same time itis provided to me or my represermtive. <br /> TYPE OF SERVICE REQUESTED: S �L'A l• L <br /> COMMENTS: <br /> JPN Po�TME j EN <br /> SN�LCN0EpPPSM <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EAPLCYEEfh DATE: 2- 3 <br /> d" <br /> ASSIGNEDTO: �(Z EMPLOYEE#: DATE: <br /> Date Service Completed ('d already completed): - SENICECOOE: 'P 1 E:. <br /> Fee Amount: ��p Amount Paid $ �� . AL2:. Payment Date ( ����y <br /> Payment Type c/ Invoice Check S?i Received By: .L . <br />