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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR BLL11HG PARTY <br /> ,TiN ter- L +4— <br /> FACILITY I h1E ' �e���7 t <br /> `� IA i A 4i95D4lti',0- <br /> SITE ADDRESS <br /> Z( L% 1 s&w Number ,EmO "'"' strove van. �7' lyp. suit.Y <br /> Mailing Address (If Different from Site Address) J f <br /> CITY <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZOY) - ?-Z-(p4 - <br /> PHONE#2 Err. BOS DISTRICT - LOCATION.4 1— <br /> CONTRACTOR I SERVICE REQUESTOR <br /> -CONTRACTORISERVICEREQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS WE Q PHONE# <br /> 1/ Ay .fJ i4Jc% .�. cFI 9P9 —1s37 <br /> MAILING Amms <br /> Civ F le 7 <br /> CITY " Cr z06' & -,0ZPy7 <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same,acknowiedge that all sile and/or project specific <br /> Pusuc HEALTH SERvtcEs Ew RONMENTAL HEALTH Or ism hourly charges associated with this project or advity will be billed to me or my business as identified on this tone. <br /> I also certify that I have prepared this application and that the work to be performed will be done in aosrdance with all SAN JoAouN COUNTY Oexence Codes,Standards,STATE and <br /> FEDERAL taws. J� h <br /> APPLICANT SIGNATURE: ��"' DATE: Z-9 —d Z— <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AumioRm AGENT ❑ <br /> If APPGCvrris not the Bri m Purr proof of wMatauon to sign is nwin d 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 amllor environmentallsite assessment information to the SAN JOAouN Cowry PueuC HEALTH SERVICES ENVIRoNmENTAL HEALTH ONISm 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 /> CotNmEtrrs: PEC v ED <br /> R <br /> SAN JOAQ�IN COuj�c <br /> FN ONMFN'iPd- <br /> INSPECTOR'S SIGNATURE: n CONTRAcToR's/SIGNATURE: / <br /> APPROVED BY: zof� EsNPL >T: `//� C C DATE: <br /> ASSIGNED TO:, 7d ._EwLOYEE#: 1 DATE: <br /> Date Service Completed (tf already completed): SERVICE CODE: `; •P l E: <br /> Fee Amount: 2 Amount Paid Payment nate <br /> Payment Type Invoice# Check 9 Received By: <br />