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SERVICE REQUEST <br /> Type of Business or Property _7FACILITY ID# SERYIC T# <br /> OWr!E�I OPERATOR --k <br /> �RIJNGP <br /> �T <br /> Lc-a< 7 <br /> FACtUTY NAME <br /> $b.rt Xrmbr Wecoen �T�t/� sb.w n+n, 'Tp. sw.r <br /> Mall g Add <br /> r ss If Difforent from Site Address) <br /> CITY - , <br /> STATE ]Jp <br /> PF(oNE#1 Err. APN# LwDUsEMwraTtoN# <br /> ( ) 466 <br /> .PHONE#2 Err. BOSIDISTRICT LoCA11gN <br /> CONTRACTOR/SERVICE REOUESTOR <br /> REQUFSTOR ^ r BILLING PARTY❑ <br /> BUSINESS NAME PRONE# rAr. <br /> -MAILING ADDRESS (FAX# <br /> CSO ! V)y <br /> CRY 1/ Lt^t ���� STATE 7jp <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or businesa- owner,operator or authorized agent of same, acknow a that 30 S40 andfor <br /> PUKIC HEALTH SUMCES ENVIRONMENTAL HEALTH OmSIONhourly charges associated with this project SpedO <br /> lxo]eU or adrviry will be billed to mo a my business az identified on lNs form. <br /> 13150 Outify that I have prepared tris application and that the work to be pedomled will he done in accordan with aU SAN JOAOtW COUNTY ORFAancg Cede;SfW8rd34 STATE an <br /> FEDERAL laws. <br /> APPLCANT SLGNATUR 'u�� � � )t���� <br /> � DATE' <br /> PROPERTY I BUSINESS OWNER O OPERATORIMWGER ❑ OTHERAUDIORRED AGENT O <br /> YAWL ,is not to DLrra'P._n...Praarafasewr6-rloe to Aha is neabwd rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applkzble,L the ow neroropenlor of tle oroperty IopLed at the above site address,hereby autllari:a the release< <br /> any and all results,geotechnical data andlof environmenlaisne assessment klforinal to the SAN JOAGUN COUNTY PUOLIC HEALTH SERWAS ENVi WMENTAL HEALTH DMSm az soo <br /> az it Is available and at the same time it Is provided to roe or my;epresentative. <br /> TYPE OF SERvict REquESTED: <br /> COMMENTS: '/f2 S C'AI��I aJ do O S 1 p/j ,.., n J/ <br /> "'p� (J `r,�'( PAYMENT <br /> ai1¢�a Ra�A-t2 4-o he 4-� RECEIVED <br /> L✓v�vf 0-1te s)f� Z x �D L.r; . SEP 2 2 2000 <br /> {ZKlDX/b� S - SAN JOAOUIN COUNT,( <br /> PUBLIC HEATH ENVI ONWNTAL HEALTH DIV SIDN <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED DY:. `— O <br /> EMPLOYEE#: DATE: <br /> -ASSIGNED To: v��-.—__ <br /> EMPLOYEE#: -DATE: <br /> 'Date Service Completed (if already completed): <br /> SERVICECODE: PIE: J7 <br /> Fee AmOunt <br /> ! AmounlPaid ��7® Payment Date <br /> Payment,Type Invoice#' Check# <br /> ,3 Received By. <br />