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SERVICE REQUEST <br /> ` Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR BILLING PARTY 0 <br /> (— � J <br /> FACILITY NAME _ .. ------- - ---- <br /> M 10 t/A-1, e-( <br /> SIT EADDRESS ,- ,fes "��-v� C— <br /> (� <br /> /& .�qq 67' StrraiHumow Dlncdon Swat Hams su,l�1 <br /> Mailing Address (If Different from Site Addressl <br /> CITY STATE ZIP <br /> L Itj0 CA- 9SZ 3� <br /> PHONE#1 ExT• APN LAND USE APPLICATION# <br /> (Z If X1 )v �'�5l o -oho _ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PART`( <br /> J� Nluf � <br /> BUSINESS NAME PHONE# FxT• <br /> MAHJNG ADDRESS FAX# <br /> v <br /> V4;:-DY- Z 1 <br /> CITY STATE c..4 Zip ci�24I <br /> LorA <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or buslness gwner, 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 big billed to me or my business as identified on this loam. <br /> I also certify Thal I have prepared this application and that the work to be performed will be done in accordance with all SAN JoAotrlN COUNTY Ordinance Codes,Standards,STATE and <br /> FcUERAllaws. <br /> APPUCART SIGNATURE: // DATE: 3 —� <br /> PROPERTY/BUSINESS OWN ❑ OPERATOR I MANAGER OTHER Aurviommo AGENT ❑ <br /> K APPLc wr is rat fha QkLtn PM Proof or authorization to sign Is requlnd Ti f 1 e <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 and/or environmentalisile assessment into oration to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH[)(VISION as soon <br /> as it is available and at the same tirne it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: L kJWCFACC Sv6fuyt1` <br /> COMMENTS: <br /> 5 �� 7/L-Qrr?�►�-52 PAYMENT <br /> ck? <br /> s z/L� tees ,e f,�/>"�� <br /> rs -r� �vn,�r� `%MAR 10 1999 <br /> V-0 705 <br /> 12 <br /> S y� SAN JOAOUIN COUNTY <br /> All vry� 7 ��� � 7NV RONMENPUBLJC TAL HFALTH DI SION <br /> p r'� <br /> INSPECTOR'S SiGNATURE: �� ry/OZt L!�`C� CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: L " EMPLOYEE#: U ( DATE: <br /> ASSIGNED TO: EMPLOYEE r: DATE: <br /> Date Service Completed (If already completed): Z(� ,G SERVICE CODE: <br /> Fee Amount: �^� Ute— Amount PaidPayfpen(Date 311 D 19 q <br /> 15(0. OrJ <br /> Payment Type Invoice# Check# 13�$q Receiyed By: <br />