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SERVICE REQUEST – <br /> Type of Business or Property FACILITY ID SERVICE REQUEST h <br /> l-r,-41r--tJze FrzoDu,-'77OA/ � <br /> OWNER f OPERATOR BILLING PARTY ID <br /> iE /-7-D-- R-27NE�ZSflif' <br /> FACILrrY NAME <br /> fz 0 Wlil,I RAN�f/ <br /> SITE AD13R�E7SS s <br /> f 3 Z D3strnt Number DlncUon D/�O A.D stmt Naml Typo Suds/ <br /> Mailing Address (If Different from Site Address) <br /> l20 L3�2— t i,l <br /> CrrY STATE zip <br /> P. 0 . 14 2 7 CA 1 -5-330 <br /> PHONE#1 EXT. APN)Y LAND USE APPLICATION# <br /> ( ) 2.5- 30-0 o fig• <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQIIFSTOR BILLING PARTY <br /> C/tr' <br /> BUSINESS N E PHONE# �? <br /> WA 66 <br /> MAILING ADDRESS FAX <br /> - D • 8 el SGB <br /> CITY eK <br /> a/e LU — STATE ,,N ZIP ' <br /> _BILLING ACKNOWLEDGEMENT: I, the undersigned property or buslnesq gwner, operator or authorized agent of same, acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges assodaled with this project or activity will be billed to me or Noy business as identified on this lona. <br /> I also cerUty that I have prepared pP <br /> lication ad�al the work to be performed will be done ip accordance With all SAN JOaouIN COUNTY Ordinance Codes, Slandards,STATE and <br /> FEDERAL laws. q q <br /> 2 <br /> APPLICANT SIGNATURE: DATE:. <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR I MA,4GER 1,! OTHER AUTHORIZED AGENT O <br /> Nl APPLCANr i;Pot(he BB iu m Pm pmol or authodzadoq to sron k"ku d <br /> AUTHORIZATION TO RELEASE INFORh1ADQN:When applicable,I.the owner or operalor of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaltsile assessment into mation to the Sul JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 /> SD L ,a/TA 0/L i D E✓r f/L�-- ___ - _ <br /> COMMENTS: 7�7'9g <br /> PAYMENT <br /> MAR - 4 1999 <br /> SAN JOAQUIN CUuN <br /> PUBUC HEALTH SER`: <br /> ENVIRONMENTAL HEALTH U <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: (� <br /> APPROVED BY: EMPLOYEE r: % DATE; <br /> ASSIGNED T0: EMPLOYEE : �� � DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: S7 )— l P I E; c2,� , -,9,1 <br /> Fee Amount: Amount Paid 5 PdyRlertt Date 3144 Iq y <br /> Payment Type Invoice# Check q Sl RecelYed By: <br />