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SERVICE REQUEST , r EHOO61SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> N�RCF i <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> i <br /> 'i FACILITY NAME <br /> C G �R t'3/ C� C/-�urZcid <br /> SITEADDRESS /f9(.-Z I �_ 5� /!T I-A?4' JTA4261 x,11 <br /> Str Nu v oin oft Street Name Type Suite0 <br /> Mailing A dress (If Different from Site Address) <br /> - <br /> CITYS/—OSTATE ZIP <br /> C i�lOn/ <br /> PHONE#1 w- APN# LAND USE APPLICATION# <br /> q'�� - I( U 0/ 3 3 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REOUESTOR nO / /r� BILLING PARTY❑ <br /> BUSINESS NAME Vag y <br /> f4//V ZE5GAf"4 P NE#��� <br /> MAILING ADDRESSP O Sax -37c74 FAJ(# <br /> Ili Cm 2 L d If le-- STATE c ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify that I have prepared this I cation at at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, STAT d EDERAL aSv �i7 <br /> APPLICANT SIGNATURE: t DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> if APPLICANT is not the BILLINGPA proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: A I L I _ <br /> COMMENTS [I SPECIAL CONDmON(S)OF APPROVAL❑❑—i�lXlJ GTHER ❑ <br /> JAN 1 -2 o99 <br /> ;NVIpC Uc Hgq"ia Cr, <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATUSE�/CfS DATE: <br /> TH OIV/SIO <br /> APPROVED BY: EMPLOYEE#: V � DATE: Z <br /> ASSIGNED TO: EMPLOYEE#: M Z DATE: 1z <br /> Date Service Completed (if already c mpleted): I SERVICE CODE: 57 Z S pit: <br /> Fee Amount: cI C) �• Amount Paid p p o Payment Date I aq I q <br /> Payment Type ✓" Invoice# Check If q(I L.f Received By: (�6, <br />