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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID it SERVICE REQUEST# <br /> OWNER/OPERl1TORBILLING PAR <br /> 03Yl� ��-lr �S <br /> FACILITY NAME <br /> SITE ADDRESS3 7 �����Y��I U 1_ 11 <br /> StrutNumbtr Direction l {(slfwHame <br /> Type Suitel <br /> Mailing Address (If Different from Site Address) <br /> o� 1 ���rc� CJS <br /> CITY l��C��t,►v►� ' C� <br /> v STATE �j � zip <br /> PHONE#1 EXT. APN# ` <br /> LAND USE APPLICATION# <br /> W ( ) aocr � -(GbS a � - o a o - Z-H -ct 7- y <br /> PHONE#2 UT. BPS DIsTRIcT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY❑ <br /> BUSINESS NAME lA t O ��soy-, <br /> ^ S�( T� PHONE# 6 7—3 ?Faro/ <br /> MAILING ADDRESS 1 J 11/�J `// F11X# <br /> 3 3 3 - �S_50 <br /> Crry LQ� STATE zip <br /> �s a v <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge ;hat all site and/or pro;eet specrc <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DnnstoN hourly charges associated with this project or activity will be billed to mo or my business as identified on thts f. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinarco Codes,Standards,STATE and <br /> FEDERAL laws. 1 <br /> APPLICANT SIGNATURE: DATE: Jy 1-7 Q"A 00 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAvpt,CAxr is not ft Ou m pAmy,Proo(of 2uthoriz2tIon to sign is roc,uirod Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY Punuc HEALTH SERVICES ENVIRONMENTAL FIEALTH DMSION as soon <br /> as it is available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: I f f <br /> COMMENTS: is J <br /> PAYM E 1' <br /> • RECEI�r'r.:� <br /> SAN JOACL, . <br /> PUBLIC HEAL' <br /> ENVIRONMFNTk <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. <br /> EMPLOYEE9: 9 I f -7 DATE: <br /> ASSIGNED TO: y I` EMPLOYEE It: j u DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: [ P I E: Z�O <br /> Fee Amount: o Amount Paid o� 15. <br /> S �'�474< Payment Date C)I <br /> Payment Type Invoice Check 9 i t l= Received By:-- <br />