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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST m <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS i/4o( _ (� 1� �jL4 Y �� <br /> EETrf��v S"et Numbv Oirecdon l SVW Nwm Type Suite 7 <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP GS G .� <br /> / JC <br /> PHONE#1 EXT. APN# LAND USE ApPucanoN# <br /> (tai) 09I -OHO - S I( , ► A41 `/� - pv(-� V <br /> PHONE#2 EM BOS DIMICT _ LOCATION CODE . <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> BUSINESS NAME PHONE# (� EXT- <br /> MAILING ADDRESS Fax# <br /> CITY .^^' STATE zip C1 -� 'Z4 c <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknaNledge that all site andlor project speGFc <br /> PUBLIC HEALTH SERVICES ENVIRCNmF-NTAL HEAL ION hourty 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 this ication a that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. /J <br /> APPLICANT SIGNATURE: DATE' 7 — U, <br /> PROPERTY/BUSIN S OWNER C OPERATOR!MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> I/APPLr—Wr is rpt UV 8QT4G Parra goof of wthar&a on No sign is rwuved rive <br /> AUTHORI7-,TION 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 insults,geotechnical data and/or environmentaltsite assessment information to the SAN JoAOuIN COUNTY Puauc HEALTH SERVICEs ENVIRONMENTAL HEALTH OMSION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE RL-QUESTED: <br /> COMMENTS: PAYMENT <br /> I <br /> 2 RECEIVED <br /> NOV - 7 2003 <br /> SANN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> INSPECTORS SIGNATURE. <br /> CONTRACTORS SIGNATURE: <br /> APPROVED BY: E:ePLOYEH#- ( DATE' Z1 <br /> ASSIGNEDTO: �L C EuPLOYEE#: L DATE: <br /> t <br /> Date Service Completed (if already completed): SERVICE CODE <br /> FeeAmount Amount Paid � Payment Date ( 3 <br /> Payment Type Invoice 4 Check 9 62 t 4,' Received By: <br />