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SERVICE REQUEST <br /> POWNIERIOPEPATOR <br /> f Business or Property FACILITY ID# <br /> hr�RlCom}�7U AL SERVICE REQUEST# <br /> tiP�: rL'zq- i�o� of SSOO -2- SO <br /> U _LjN`( Vel. ANG pof�F�l�i fel T©rSFs BILLING PARTY❑ <br /> FACILITY NAME <br /> SfTE 70� <br /> (l �T�i N E Co l <br /> Str��t Number 6lrectian SVM Name <br /> Mailing Address (If Different from Site Address) TYP' s°II.` <br /> CITY <br /> ;cFyl_or1 STATE zpEg 521= <br /> PHONE#1 APN# LAND USE APPLICA ON# <br /> (Zc'� 838 2fi�,o5 <br /> Z2 LAND <br /> PHONE#zT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REOUESTOR <br /> AL-TE-k L G u R:n S BILLING PARTY <br /> BUSINESS NAME G(Vtl_ 1E t--1GAt N EElzl NG PRONE# EXT. <br /> L� 3 <br /> MAILING ADDRESS 4-16 «ATTNE.W PLS LA FAx# <br /> CITY L 01) I STATE ZIP �"' <br /> L 4-a <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project spedre <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION 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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: 7/0 G <br /> i <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CIYf� �iTk <br /> IfAvrt cANris not Iho 1/41rr2 E,vrtY,proof of 2uthoeizadon to sign is ro-q u;41 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 environmentaUsile assessment information to Ude SAN JOAQUIN COUNTY Pumic HEALTH SER=ES ENVIRONMENTAL HEALTH Dlwslou 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: Sal L SIOI'[%4�f11 iY. 3Tl'U� SCF© iY! > <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: <br /> CONTRACTOR'S SIGNATURE: <br /> APPROVED DY:. EMPLOYEE#: C DATE: <br /> ASSIGNED TO: 6�0rivy, EMPLOYEE If: DATE: <br /> Date Service Completed (i ready completed): SERVICE CODE: p/E; <br /> 57.E Zl <br /> Fee Amount: 7 !? Amount Paidc¢ U Payment Date <br /> Payment Type Invoice#' Check# <br /> L�cl�) Received By: <br />