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0 i SERVICE REQUEST O© <br /> Type of Business or Property FACILITY ID# ✓0 <br /> SERVICE REQUEST# <br /> ell <br /> OWNER I OPERATOR <br /> 00 ViN <br /> FAcrurr NAME \ V ti I-e— L tou 0 <br /> 1 <br /> SITEADOREss (j 2 SO �. <br /> Lt J ewv\ 2vcac.� <br /> Str•arHwnbu arr•cvan SVM Ham. <br /> Mailing Address (if Different from Site Address) Try suns <br /> 6 CITY STATE zip G <br /> PHONE 1 1 T E:r• APN 0 LAT10 USE APPLICATION 9 <br /> PHO c#2 En. <br /> I30S;DISTRIGT LOCAT)6N CODE: <br /> REauEsroR <br /> CONTRACTOR!SERVICE REQUESTOR <br /> � <br /> G f ! BILUHG PARTY CI <br /> 10 <br /> BUSINESS NAME rJ PPHHONE9 <br /> rjL Exr. <br /> MAILING ADDRESS / <br />� FAx# <br /> C 33 '9 1)0 <br /> C" d� ( STATE ZIP <br /> i <br /> 3 BILLING ACKNOWLEDGEMENT: f, the undersigned property or business owner,operator or authorized agent of same,acluro+vled a that all site andlor <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DnnSION hourly charges assoaated wtth Ibis projector activity will be billed to mu or my Easiness t identified an this fommiect speafic <br /> i I alsocertify that I have pre this appllc;ation and That the work to be performed will be done <br /> EEDER/4l•laws. in accordance with all SAN JOAOUIN CCUNTY Ordindes <br /> anca Co ,Slandarrls,STATE and <br /> E EOE <br /> <APPLICANTSIGHATURE: <br /> DATE: J <br /> PROPERTY/BUSINESS OWNER Q OPERATOR IMMAGER Q OTHER AUTHORIZED AGENT ❑ <br /> ItArrr.:cmr is eoi Iha a U MZA_my pnoor of aufhodzadon Tv sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.G the owner or aperater of the property+located at the above site address,hereby auihorize the release of <br /> any and all results,geotechnical data andlor environmentallsite assessment inrormatian to the SAN JOAotmr COUNTY PU6LIC HEALT"SERVICt 5 ENvtRONMENTAI HEALTH DnnS1ON as soon <br /> as it is available and at the some time it u provided to me or my representative. <br /> _ <br /> TYPE OF SCPAYMENT REQUESTED: t' RE � <br /> COMMENTS: -V94 <br /> AUL <br /> 2 / coUNTY <br /> SAN JOAQUIN <br /> r E PUBUGH�{THSERHiCEUIVSSJON <br /> PARbl`WAr <br /> JUL U <br /> tA <br /> d'!e� SAN jOAQUYN <br />` UNTY <br /> INSPECOR'S SIGNATUR d PUBLIC HEALTH SERVICES <br /> YCOkgCTOR'S SIGNATURE. ENVIR tOENTALHEALTHDIVI5 <br /> io <br /> N <br /> APPOV :. <br /> F EMPLOYEE : DATE: <br /> j -'As SIGNEuTo: 7 d 2 <br /> EMPLOYEE : DATE: <br /> Date Service Complet (if already co leted): <br /> SERVICE COo>_: P!E: :. <br /> Fee Amount; <br />' Amount Paid �� Payment Datc <br /> f Payment Type l� Invoice 9• CtTecfc# �/ /1_ <br /> Received By: <br />