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`+ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# VSERVICE REQUEST# <br /> -773 <br /> OWNER OPENATOR <br /> BILLING PARTY❑ <br /> FACILftt NAME <br /> SITE ADDRESS <br /> ` T Sbut Nump.r grecuan I�..�� � \ $bed N+m. <br /> Mailing Address (If Different from Site Address) v snll.r <br /> Crry <br /> STATE <br /> PHONE#t Tm. APN# LANE)USE APPLICATION# <br /> ( <br /> PHONE#2 tn. BOS:DIsTWCT LocATC N CooF: <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REggqU TOR ' <br /> BILLING PARTY . <br /> . .BUS NAME^ U� �[ � MXL' PHONC# Un, <br /> An <br /> AAILRiG ADD ESSY✓F�-`'l0 FAX <br /> IoZ�0l <br /> CITY <br /> Cd <br /> *Tt� STATE <br /> BILLING ACKNOWLEDGEMENT Undersigned property or business owner, operator or aU(tioriZed agent of same, aeknowLdge that all site and/or pmimt spcdl�c <br /> PUDLIC HEALTH SERVICES ENvwam EALTH DIVISION hourly charges associated with his project or activity,will be billed to me or my business ,idenGGed on UIL form. <br /> I also certify that I have prepare pli n and that the work to be performed will be done in accordance with all SAN JOADUIN CCUHTY Ordinanco Code:,Standards,STATE and <br /> FEDERAL laws. <br /> P PUCANTSIGRATUR ' Carr. II o�/ <br /> DATE: Car I {' <br /> PROPERTYI BUSIN 55 thhTr r —�--- <br /> ❑ OPERATOR/MANAGER ONIERAUTHONZED AGENT Cl <br /> Ir Avrruwrisnotthofl ry'x.P,vm pvprof suthodrsdon to sign Is mquhvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I,the Omer or operator of the property located at the above site address,hereby aUUtodze the release of <br /> any and all results,geotechnical data and/or envimnmentafto assessment information to the SAN JOACUIN COUNTY PUDLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSIOv n <br /> as it B available and at the same lime it is provided tome or my rcpresentadve. as soo <br /> TYPE OF SERVICE REQUESTED: I I <br /> lA <br /> COMMENTS: (012 5-( <br /> t f n ( v(�l +/ <br /> PAYMENT <br /> I�/ I `�f/� <br /> RECEIVES ra n`� <br /> ��1%2 <br /> SRN JOAQUINHEALTH COUNTY / Cl <br /> ' <br /> PUBIJC HEALTH SEF.VICE= ,1-(7/2 �/0 I <br /> FWOR'SSICE7TURIC- `r. .>I;,'^ !/! <br /> INSVECiOR's$IGNATURE;122 PPROU6� _ CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: ©�^ 1 <br /> O--{J \ DATE: <br /> ASSIGNED TO: EMPLOYEE F: <br /> DATE: <br /> :Dale Service Competed (it already completed): <br /> ( 0 2 J 0�_— SERVICECODC: PIE: <br /> Fee Amount: V"7 g Amount Paid /7 U _ Payment Datc 0 <br /> Payment Type Invoice 9' Check +) G <br /> (0 Received D <br />