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' SERVICE REQUEST <br /> hype of 6Lsiness or Property —7 . -FACILITY ID# SERV CE REQUEST# <br /> —� Q <br /> OWNER I OPERATOR <br /> 010 <br /> BILLING PARTf PARQ <br /> FACILITY NAME -� ' �'`Y/ <br /> SITEADDRESS 4.Q �I <br /> /�7�.y�7 Stan Number Dkee6on •�'C�GC.JGL�� ®. <br /> sveec Na"" Troe sine a <br /> Maiiing Address (If Different from Site Address) <br /> CITY <br /> 9Y6 <br /> G�®L _ STATE�. Zip <br /> {HONEDS T APN# Q a — /� LAND USE APPL[CATION# <br /> 'e T d'_ `�O <br /> PHONE#2 UT. [13—OSDISTRICT. LocnoNl:Com. <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR 13UWG PARTY❑ <br /> BUSINESS NAMEShe PHONE#zey �4-�-z�z <br /> MAILING ADDRESS <br /> FAX 9 <br /> 4 D 4�s <br /> CITY � G STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION hourly Charges associated with this project or aclivity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the rk to be performed will be done in accordance with all SAN JOAoUIN COUNTY Ordinance <br /> FEDERAL laws, Codes,Standards,STATE and <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY)BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> YAratr wris nod doe B+rca,raParry Proof of authmization to sign is rnquirod T I e Q r <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 i <br /> any and all results,geotechnical data andlor environmentatlsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERvrcts EwRONMENTAL HEALTH DIVISION as soon <br /> as it Is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REgUESTED:�I-r r / <br /> COMMENTS: <br /> PAYMENT <br /> ,.�fi q RECEIVED <br /> /Vr 2 y z ��f � ��o LL•-;T <br /> 5 r z i t'h a 7-V g <br /> f vUIN COUNTY <br /> /`Y '/ BLI aHEOALTH ERMCES <br /> L ENViRDNrvtEWX?.TH DIVISION <br /> INSPECTOR'S SIGNATOR CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLoYu M 4n; <br /> � /� – VICE <br /> RASSIGNEDTO: —Coo <br /> Date Service Completed (it-already commpleted): CODE: <br /> Fee Amount: nAmount Paid oVICE C <br /> n () Payment <br /> ent DatSre <br /> — <br /> / qP,!ED <br /> Pa mTyP Oeat e voice Check# <br /> 3 <br /> Rdceived By: <br />