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' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R/C4/1-TU,eA L Rif/GENT/a 4- <br /> OWNER/ <br /> -OWNER/OPERATOR BILUNG PARTY❑ <br /> VE M E2 <br /> FACILITY NAME <br /> SRE ADDRESS4r <br /> n <br /> 33 0 Street Number Direction Street Name Type Suite a <br /> Mailing Address (If Different from Site Address) <br /> CITY / NTS.LA e STATE CIA, ZIP <br /> s3 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( y0 -O40-/I -f i L IVs r /Sfe,,E Ye <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILUNG PARTY <br /> BUSINESS NAME PHONE# • <br /> V- 403 <br /> MAILING ADDRESS FAX# <br /> l3otC 3?�� <br /> CITY STATE 1 ZIP'�'S-30 / <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 certify that I have prepared kation and thattI9 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: ATE: A!—Z-7 <br /> PROPERTY <br /> /- <br /> PROPERTY I BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AG ❑ <br /> If APPLX)Mlr is not the Biuwc PAmv pruo a onzabon to sign is required Title <br /> AUTH0RtZATION 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 environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DlvisloN 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 /> J~ACE AND sdtjsu,tFirt ca-:; CoA1TR/Y!i eVA7',,o.,/ RE?"b27- ,QE✓/EW <br /> COMMENTS: <br /> NOV 22159 <br /> SAN JOAOUIN:,GUN iN <br /> PUBUC HEALTH SERVICES <br /> ENVIRONMENTAL.HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: "� - Y� CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: <br /> re--- —7-4-4-4 <br /> 7- r,�C EMPLOYEE#: �O6 I DATE: / �ZW <br /> F� / <br /> ASSIGNED TO: C.5 70�0014 EMPLOYEE#: Z) DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P f E: Z,e, ozJ <br /> Fee Amount: lr'6 Ste— Amount Paid S6 � Pa;rment Date It-!Z 9 <br /> Payment Type ��dcG� Invoice# Check# G 7 Received By: <br />