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�.- SERVICE REQUEST -- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1cUL-rURAL AF'N: Z2�- 11� S�oO 2- <br /> OWNER I <br /> -OWNERI OPERATOR vEtJ uY W. A1vJD TV NA Mt• SnC�j BILLING PARTY 0 <br /> FACILITY NAME <br /> SITE ADDRESS (lec lvg2- <br /> Street Number Direction SVeetflane <br /> YYPe —Sulfa t <br /> Mailing Address (If Different from Site Address) <br /> CITY F_,rAl �f i STATE _ -CA ZlP <br /> PHONE#1 Ear,. APN# LAND USE APP TIO # <br /> (Zr)g) 638-2805 <br /> PHONE#2 Ex 1. BOS DISTRICT LOCATION CODE' <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY( <br /> WAL1'E� 1E. C V Fri is <br /> BUSINESS NAME PHONE# EXT. <br /> C tv's 4 Ere+cx�►��.>;� `lam - l� <br /> MAILING ADDRESS FAX# / <br /> +16 MR ver Pt_. zA <br /> CITY L oU( STATE ZIP 9 s z� <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 DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certily that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. R <br /> APPLICANT SIGNATURE: �/ �iL�SQJ DATE: O'}/f I 10-Z <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER O OTHER AUTHORIZED AGENT X C I V I L i=N �Q i W 1-=7r= EZ <br /> If APR,cANr is not the Gum P wn proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby aultaorize the release of <br /> any and all results•geotechnical data and/or environmental/site aSSCSSment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DrvISION 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: S r <br /> COMMENTS: kL,,`Y <br /> PAC <br /> ��► Knot,v we r�� <br /> RECEIVE.'-') <br /> APR 11 Hr? <br /> SAN JOAQUI'; <br /> PI!"�IS In^ <br /> ENVIE' <br /> INSPECTORS SIGNATUR CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: <br /> ,(� DATE: � i1 r7 <br /> ASSIGNED TO: � /- O EMPLOYEE 9: G 2 7 DATE: V C. <br /> Date Service Completed (if orcady completed): / / SERVICE CODE: f.S P/E: Q <br /> Fee Amount: Amount Paid ' _ Payment Date <br /> 41441 u <br /> Payment Type Invoice; Check# j Received By: <br /> i y/� <br />