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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SI=RVICE REQUEST I# <br /> X51 D41C' � 20 ",/ 1 1 01s5c) <br /> OWNER/OPERATOR BILLING PART,',D <br /> PE� // <br /> FACILrrY NAME <br /> 7 f M.9 NCH LAND COAPAAl <br /> SITE Ao RES$/ S �7 /`e ley ROAD <br /> Q"�-// q Street Humor Dlncvlon shed H&me Type Suue! <br /> Mailing Address (If Different from Site Addressl <br /> CITY STATE zip <br /> -T PHONE'rY1 APN# LAND USE APPL�TION# <br /> PHONE#2 EAT. <br /> CONTRACTOR <br /> DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQIIF.STOR BILLING PART`( <br /> �d N C���N� <br /> BUSINESS NAMENONE# �? <br /> ALS - Sp�C'�o-i�/--- z� s,2 <br /> MAILING ADDRESS FAX# <br /> 9�0A&b y T-J7-4.4 <br /> CrTY /-(0 ge-Cro STATEM ZIP j 3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowl9dge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION dourly Charges assodaled with this project or activity will be billed t0 me or my business as Identified on this loan. <br /> I also cenity that I have prepared th' pplicadon a at the work to be perlormed will be done ift accordance With all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR I Mn GER IIY OTHER AUTHORIZED AGENT ❑ <br /> #A rispotfhaBtLmPARrrproororaurhortzsUoaroslpnIs"k!d Till@ <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable•I,the ovmer 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 environmentallsile assessment into inrtion to the SAN JOAQuIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OonSION as soon <br /> as it is available and at die same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> SO /G 5Cf/TA f?/1- <br /> COMMENTS: <br /> /LCOMMENTS: <br /> PAYMENT <br /> RF-CEITe en <br /> MAR 41999 <br /> 8ANJPUBLIC OAQUIN COUNTY <br /> ENVIRONMENTAL Ni SERVICES <br /> EALTH D1VISrpry <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: <br /> EMPLOYEE M. / DATE: <br /> ASSIGNED TO: EMPLOYEE#: C DATE: <br /> Date Service Completed (if already completed: .i�" CSERytcE CODE: �/� 7 1 P/E% <br /> Fee Amount: / �j,LOv Amount Paid (�� Paymen(Date 3�y 14L Gi <br /> Payment Type Invoice# Check# PuL Recpiyec( By: <br />