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I <br /> f. SERVICE REQUEST EH0061SR revised 09/04/98 <br /> Type of Business or Property FACILITY ID# TICE 10E RE S <br /> kGIZIcuL-rt�RA1 -��Z1C� t 'US-716�1 API-4-, 207—o2�-2� Q <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> �-'•;&1�-: I 1 <br /> FACILITY NAME <br /> (SA-41-41S As dwVER <br /> SiTEADDRESS �'5z8is 5�) rtiC7�� <br /> Street NL Direction sheet am Type Suite# <br /> Mallinq Address (If Different from Site Address) �RoRY� o ZZtGk C��7.�Ft-1 19-r=i rl ARIylS' <br /> .323 SK1Fes' '�op.'D (�u15 <br /> C �CSTATE C^ ZIP � �26 U1S <br /> SC�*�C7� 17#1 <br /> � <br /> PHONE#1 APN# 2b`7_ a20 O1 LARD USE APPLICATION# <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> 04-72 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR WALE►' lam, CUPT(S BILLING PARTY <br /> BUSINESS NAME PHONE# - �T• <br /> OF- sQM� lis A�Yz�3 .� 4s <br /> MAILING ADDRESSFAX# <br /> 4k8> MP,77 4 W '�t�ZA <br /> CITY L 6DI STATE C A, ZIP 9s24-o <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator o authorized agent of same acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges assn wl Is project or activity will be billed to <br /> me 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 be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT SIGNATURE:. DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT C 1�l)� �I Gt11�1 EPS __-- <br /> IfAPPuCANTis not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, t, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical dela and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPEOF SERVICE REQUESTED: 1)SLL*FACE AW) SU$SURFACIE Co1-�M11-1AT1014 REF �Q--r RE/Ilew <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER <br /> REG <br /> 00 <br /> QUg1.MEN�P�, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: 1 1 EMPLOYEE#: DATE: 11.11-00 <br /> ASSIGNED TO: EMPLOYEE#: DATE: `���.0 <br /> i v <br /> Date Service Completed (if already completed): SERVICE CODE: �rj P I E: D <br /> Fee Amount: rl <br /> / Amou t Paid Payment Date <br /> Payment Type e4k�C.y Invoice#' Check# Recefyed By- <br />