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30 <br /> SERVICE REQUEST (90 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER I OPERATOR <br /> BILLING P <br /> �o Y1�n CZ a c.k 1-e <br /> FACILITY NAME tcju 0'u-L —L Iltc <br /> srraADgREss - S'o �.I ewfdt.. 2c�car,� <br /> sv..r a,m.-. =-- <br /> MalEing Address (I(Different from Site Address) --'' <br /> k <br /> CRY.. OGt STATE ZfP G <br /> PHONE 'I W. APN# LAND USE APPLICATION II J'' q <br /> 127 <br /> Pxo >�#2 SOS D1sTRtcrI LOCAT)o>a.CoDE: <br /> CONTRACTOR I SERVICE REQUESTOR i <br /> REQUESTOR V BatmGPARrtp <br /> q. r <br /> 00 <br /> BUSINESS NAME PHONE <br /> MJUUHG ADDRESS FAX <br /> -3 <br /> o/+ If STATE .Zip <br /> BILLING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or Authorized agent of lame,acknowledge that all site and/or project,specitic, <br /> Pusue HEALTTT SUMCES ERMONmENTAL HEALTH DNm*N hourly charges associated with Ibis projector activity will be baled to me-or my business as identified on this farm- <br /> 1 also certify that i have pre Ibis application and Thai the work to be performed will be done in ak>cordance with all SAN JOAQUIN CCUNrr Ordinanco Codes,5landanls,STATE and <br /> FEDERAL laws. _ , ,.. <br /> -<APPUCANT SIGNATURE: DATE: S <br /> PROPERTY I BUSINESS OWNER a OPERATOR I MANAGER 0 OTHER AuniORIZED AGENT 0 <br /> FAM.,-W is nd thn allt5 n,pna(of authoriuden to Jipn is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I.the owner or operator of the property located at the above site address,hereby authorim the release of <br /> any and aA results,geotechnical data and/or environmentatfS40 assessmernt information to the SAN JCAOum COUNTv PtmuC HE v.Ttk SERvicis EwiaoRmcNTAL HEALTH DIvis=.N as soon <br /> as it is available and at the same time it is provided to me or my representative. �Y ENT <br /> TYPO of SERVILE REQUESTED: E <br /> COMM@NTS: �r i JULSkN ' : <br /> .. COUIN COUNTY <br /> PUBLICHEAL S RVICES <br /> • IVIBiDy ' <br /> N- ASH D - <br /> E � Tra - - <br /> ' IF D <br /> .J U L 2092 `c <br /> SAN JOAQUIN COUNTY. <br /> INSPECTOR'S SIGHATUR CTPUBLIC HEALTH SERVICES <br /> ES <br /> SIGNATURE:: ENVIR OEN1W,L HEALTH MWON <br /> APPROVED BY:_ Eh1Pt oYEE 9: DATE: <br /> d <br /> ASSIGNEDTO; <br /> EMPLOYEE 9: f r DATE: <br /> .Date Service Complct {if already co Icted): - �2: ! . SEmn[ECODa <br /> 'PI 66 <br /> >w. <br /> Fee Amount: <br /> Amount Paid.J 4^ Payment Date <br /> Payment.Type Invoice tI Check A Received By: vvnn Vis` <br /> r <br /> W - <br />