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L SERVICE REQUEST <br /> of Business or Property FACILITY ID# SERVICEREQUEST! <br /> LNE OPERATOR CHECK If BILLING ADDRESS❑ <br /> TV <br /> FACILITY NAME <br /> SITE ADDRESS t/ /�/J <br /> 3�d 3 j�( L Se (iS11 a Trun Svte 4 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY I,O STATE ZIP <br /> ✓V O <br /> L H <br /> PHONE#I "T. APN# LAND USE APPLICATION# <br /> PHONE#Z E+T• BOS DISTRICT LOCATION CODE <br /> b. t <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR C//ECK I(BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS Fuc# � <br /> ( ) <br /> � CITY /I STATE <br /> ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator Or authorized agent of same, <br /> a_ acknowledge that all site and/or project specific PUBLIC I{EALTH SERVICES ENVIRONMENT.LL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and t the work to be perforated will be done in accorda%Ce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE " DERAIL la s. <br /> APPLICANT'S SIGNATURE: DATE: d <br /> y <br /> PROPERTY/ BUSINESS OWNER OPE OR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the G .t proof of authorization to sign is required Title <br /> AUTHORIZATION TO RFI EASE INFORMATION: When applicable, f, the Owner or operator of the property located at the <br /> L above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> inlormalion to the SAN JOAQUIN COUNTY PUBLIC HEALTIf SERVICES ENVIRONMENTAL HEALTIf DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: V <br /> rb-6-9N Q�I�rrr�f v`r�lt_ <br /> ._ � F _ v)°1Pm is �u+ toJliwletp; <br /> r✓ /le > pul�n f�r7te Qn �rNe2+ ��v�ttiNT <br /> fZrnd t iihl� sn jurrYd. FFt fyAir�"4* exls,,n sylaq RECE;VED <br /> r <br /> re" I k✓ ✓f A riiT- <br /> lrNe wUtlILvdc aIIO�Ned G/r}�cr" r•Yb�[ is y OCT <br /> �G <br /> INSPECTOR'S SIGNATURE: <br /> CONTRACTOR'S SIGNATURE: I <br /> ICODE: <br /> APPROVED BY: PJp(n EMPLOYEE#: ' EN I ENTA gISIONASSIGNED TO: 1(jy/I�O EMPLOYEE#: DAIE: /D �(% /Dale Service Completed (if already completed): SERVICE P f E: (�Fee Amount: Amount Paid Dale <br /> Payment Type Receipt# Check # Received By: <br /> SRRr:OrmAw 7/1/1999 <br />