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• SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -,0� 5 <br /> OWNER/ OPERATOR <br /> 1•� � 11 � �'�. C D ��� �5 CHECK I(BILLINGADDRESS <br /> 4e,- <br /> FACILITY NAME GSC <br /> SITEADDRESS / " 71_ I-4 Q/y,0 ,`/ �r. <br /> 1`'�'� TYue I guile M <br /> �D �P St�ssiNuRLbst I t2lrasi4 cast�gme <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE ZIP <br /> LAG e or� � <br /> PHONE#1 EXT. APN LAND USE APPLICATION# <br /> ( ) /Q,-fie 0/9-060 - Z S • , ; <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME NONE EXT. <br /> a <br /> /UrL LQ`S Za <br /> HOME Or MAILING ADDRESS FAX <br /> CITY vG O� STATE C ZIP 5ZV 7 <br /> RII 11NG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC III:AI_Tli SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �f 9 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> /f A!'PL/C.INT is not the[31LL1NG P.IRTY.proof of authorization to sign is required Tlrlr <br /> AIJTl10RI7ATI0N TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IlEALTII DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIVED <br /> 3EP lfflo <br /> SHIP Jl.'rJUtlV i..UUI� <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE 17 <br /> �cJ i <br /> ASSIGNED TO: U EMPLOYEE�: K DATE: 12'ow, <br /> Date Servico Complotod (if already completed): _t C( SERVICE CODE: 3 1 P I E:Z CD 0?� <br /> Foo Amount: l Amount Paid Payment Date <br /> Payment Type V Receipt of Check # Recelved By: <br /> SRRL•grcv Joc 7/1/1999 <br />