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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &71Z I L Z D A I rz t7bD �?i 4c-go o <br /> OWNER OPERATOR BILUNG PARTY❑ <br /> RA 11 f3Es <br /> FACILtiY NAME ' <br /> OVAIKE5A&A DA R <br /> SREADDR✓E7SS S GlA 0 /VD ` <br /> C ' &"3 d 62Str��t Numbr Dhdon SVM Nam r SuN�a <br /> Mailing Address (If Different from Site Address) <br /> /`/I <br /> CITY ^ ,V^ / 9 e STATE C� LP <br /> PHONE#1 / �' 1 fir• APN# - LAND USE APPLICATION# <br /> ( <br /> PNONE92 �• BOS DLSTRIET LOG1TpN.CODE - <br /> ?`��' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> 60 rJSi�'E BLL1,INGPAIm <br /> BUSINESS NAME <br /> PHONE# E_. <br /> MAILING ADDRESS AX <br /> P d . 3O X 7 Flo 'Z S J� <br /> Cm u 2 <br /> STATE Cil ZJP <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 projector activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this a tion and Nal rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards•STATE and <br /> FEDERAL laws. C� <br /> APPLICANT SIGNATURE: DATE:-. / /T/ <br /> PROPERTY f BUSINESS OMER ❑ OPERATOR/MANAGER OTHERAUTHORIZEDAGENT <br /> IIAPKf wrlsndf iig.rrcPunv prop/of au(harrtadon ro arpn kroqudM rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the Omer or operatorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentattsile assessment information to the SAN JOACOIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same eme it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> e;a//_ Uy a t i �TI�lD �✓I T2 4TE GOADiniC Q�L'/E( li' <br /> COMMENTS: <br /> l 11/30'/2..( PAYMENT <br /> RECEIVED <br /> 1 8 2000 <br /> a SAN JOAQUN GOUNTY <br /> 3Q EMIPuBuc NT ALTHEALTHIDIVSSION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. ' 1 EMPLOYEE#: ' DATE: <br /> -ASSIGNEO.TO: y �L . ATE: <br /> Date Service Completed (if already completed): / SERVICE CooE: <br /> P/Er <br /> �S '=� SSS a Z <br /> Fee Amount: Amount Paid iq � c _ Payment Date c � <br /> `t l- -cz., <br /> Payment Type C �l Invoice#' Check# <br /> C r` Received By: <br />