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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> S ROO 3 <br /> OWNER/OPERATOR n <br /> / Q / BILUNG PARTY O <br /> FACILITY NAME Fo or r^'5 <br /> ^'> <br /> c r <br /> $READDRESS 1 �C( � L �n r ��� ^ ��� //��(,^ <br /> l IttNumber Dir .. IC S4.ttNam• J Dr 1 C.� <br /> Mailing Address (if Different from Site Addressl Tro• sin., <br /> CITY <br /> /' Jn t 0, STATE r/t, ZfP g <br /> v li• li <br /> PHONE#1T- APN# S'� -pLAND USE APPLCATION(AVT � # <br /> - <br /> HONE fI !J�LOCAT!?�'BOS,Dtsa .CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> y REQU ;TOR <br /> BILLING PARTY 0 <br /> BUSINESS NAME PHONE# Exr. <br /> P <br /> MAILING AnDRF$S <br /> 3 0 r FAX if <br /> o <br /> CRY STATE Zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 projector activity will be billed tome or my business as identified on this form. <br /> I also certify that I have preps is application and that work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws, e <br /> xAPPLICANT SIGNATURE' — DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER O OTHER AUTHORIZED AGENT 0 06v t <br /> I/Avpucwris not the Dw+cPurrr proof of juthoruatlon to sign is Muirod itle <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 ail results,geotechnical data and/or environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DrVisON 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 /> COMMENTS: r J UA <br /> ��Y� ;�v CD/WMENT <br /> 1!z- z- 1-iECEIVED <br /> �v U SEP 1 2002 <br /> SFA JOAQUIN COUNTY <br /> H SERVICES <br /> ENVIRONMENTALp1jItl IG TH HEALTH <br /> DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. �r f` Eh1PL0YEE#: 7J 2, <br /> Wu' � DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE#: <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> J� L� PIE: <br /> Fee Amount: Amount Paid <br /> I (-Jd' Payment Date f o Z <br /> Payment Type Invoice#' Check 953� Received By: <br />