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• ti+ SERVICE REQUEST <br /> ffFAciuTYNAmE <br /> or Property FACILITY ID# SERVICE R QUEST 9 <br /> 5 <br /> OWNER <br /> BILLING PARrr,� <br /> SITEADDRESS /ilea N S-7--4W57- sr <br /> Strell NumAer DNedon SbM Nam G <br /> SvNi <br /> Mailing Address (If Different from Site Address) T". <br /> 36 05- 1`47- i 9242 r3�r sc/r� iso <br /> CITY L14'549"e7TC STATE ZIP <br /> p � 9�s�9 <br /> (�i� zo3- SS60 APNf! �S LWDUSE9ePLICATON� <br /> -�- s9 /-'A--eIoo3 6,9 (In5 <br /> PHONE#2 rn. BOS:DISTRICT LocATIOy..0 <br /> CONTRACTOR I SERVICE REQUESTOR UC <br /> REQUESTOR <br /> BILLING PARTY 0 <br /> BUSINESS NAME <br /> MAILING ADDRESS QJ� <br /> t�oX /moo FAX <br /> CITY <br /> c.¢ <br /> STATE ZIp <br /> BILLING ACKNOWLEDGEMENT: I, 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 activity 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 work to be performed will be done in accordance with all SAN JoAouIN C <br /> FEDERAL lam. WIfTI'Ordinance Code;,Standards,STATE and <br /> APPLICANT SIGNATURE: DATE: /�/�J <br /> PROPERTY/BUSINESS OWNER A I <br /> O ERATOR/MANAGER OTHER AUTHORIZED AGENT Q <br /> 11Aa wrlsnorrhepau+cPAwlYpruofofauthodradon to sign is raquirvd rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I,the owner or operator of the property located at the above situ address,hereby authorim the release of <br /> any and all results,geolechnical data and/or environmentallsito assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 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 REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JUL 2 5 2007 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED DY:. EMPLOYEE M <br /> DATE: 7 <br /> -ASSIGNED TO: P EMPLOYEER: er� DATE: —7 <br /> Date Service Completed (if already completed): SERVICECODr. <br /> PIE: <br /> Fee Amount: ��o ,cti Amount Paid <br /> d Payment Date -7 -2 S D-7 <br /> Payment Type Invoice p' Check ft <br /> 5 -5 Received By: <br />