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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID m SERVICE REQUEST <br /> OWNER 1 OPERATOR BILLING PARTY❑ <br /> �R,o,rl►L Mar2sc. <br /> FACILITY NAME /�,` <br /> SITE ADDRESS ( 6-7(p E , S A2UF�T' (ZOAl� <br /> S"ef Number Direction Street Name Typ• Surte. <br /> Mailing Address (If Different from Site Address) <br /> C rrf S rATE CA ZIP $Z ID <br /> PHONE 91 PN# LAND USE APPucAnoN 9 <br /> 053-flo - o3 <br /> PHONE#2 T SOS DlsTmcr LccATIoN CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILIJNG PARTY <br /> M <br /> BUSINESS NAME PHONE# EXT. <br /> Mue,/? 7- 33 -66/3 <br /> MAILING ADDRESS FAX# <br /> ($� t ,Wkd LN . SJIf (Zfl) -33y - a7Z3 <br /> CTrY STATE zip <br /> moo: <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andlor project spedfc <br /> PUBLIC HEALTH SERVICES ENVIRCNmENTAL HEALTH DmsioN hourly charges associated with this pmied or activity will be billed tome or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will b In accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE' DATE' <br /> PROPERTY I BUSINESS OWNER CP <br /> I h1ANAGER ❑ OTHERAUTHop=AGENT ❑ <br /> ItAPPLGwr is nar Ue 6cum Pamv,proof of autharintion to sign is mquirnd 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 PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DrnS CN as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Su. L7—A Atct .r <br /> COMMENTS: <br /> PA`.%jriEN7 <br /> RECEI JED <br /> 4 2004 <br /> l 1 �� SAN JOAQUIN ENViviONME O ANTLN <br /> F-Y•t/'�^^' I..IEALTH DEPARTMENT <br /> C <br /> INSPECTORS SIGNATURE: ONTRACTOR'S SIGNATURE:,� �n <br /> APPROVED BY: C -C V EdPLOYEEt c -2,Z� DATE' G? 2_ <br /> ASSIGNED T0. EHPLOY EE #: S 3�- DATE: [ Z (? <br /> Date Service Completed (if already completed): SERVICE CODE2Z P 1 E:. <br /> Fee Amount: _ LI-L) Amount Paid 16St. Payment Date RP-Iflo 14 <br /> Payment Type Invoice Check �L(3 Received By: - `� <br />