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i SERVICE REQUEST <br /> N. SERVICE RE U T <br /> Type of Business or Property FACILITY ID# <br /> 2 <br /> L BILLING PARtt <br /> OWNER I OPERATOR � <br /> dune W• /Yle//o Tea ' <br /> am 71 <br /> FACILrTY NAME <br /> ISff ;ADDRESS /t-r �1 <br /> GO 16treFfumor DirectionStnau Hsme TYos Su r <br /> Mailing Address (If Different from Site Address) <br /> 1P <br /> STATE ZIP <br /> CITY d'0q <br /> PHONE#1 T• APN 9 LAND USE APPLICATION# <br /> ( <br /> PHONE#Z ` B SS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> BILLING PARTY❑ <br /> REQUFSTOR <br /> PHONE# EXT. <br /> BUSINESS NAME _- -- —_ ------ a2 0 9 — l 3 77.c-- <br /> C-i Fax 9 <br /> MAILING ADDRESS - O 93 — 237-3 <br /> Jr-3 5-3— .S c/4 r, /�4n r—(7 <br /> STATE ZIP qS2 is <br /> CfTY feG� C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBuc HEALTH SERvias ENVIRONMENTAL HEALTH DIVISION hourly charges assocated with this project or activity will be billed ro me or my business as identified on this form. <br /> I also cenily that I have prepared this application and that the work to be performed will be done in a=rdance with all Sat+JOAQUIN COUNTY Ordinance Codes.Slandards,STATE and <br /> F_OERAL laws. <br /> DATE: 3 _ 2 <br /> APPLICANT SIGNATURE: <br /> PROPERTY 1 BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIzED AGENT ❑ <br /> if AffLcANr is not rhe BU e,G P;an proof of audwmadon to sign is required i ilia <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I,he 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 envlrenmentaVsite assessment into matron to the SAN JOAQUIN COUNTY PuBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> i TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ft27ft <br /> p f40 <br /> �NMEN Hil$��V Cog <br /> LTH Ills/ply <br /> INSPECTOR'S SIGNATURE: C CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:---\ I EMPLOYEE 9: / ( I DATE: <br /> ASSIGNED TO: I SMPLOYEE R: l r I DATE: <br /> -r N. LII.JJJ .� <br /> Date Service Completed already completed: �T3 7-Qv SE CE CODE: I P I E: Q <br /> Fee Amount: Amount Paid o I Payment Date J <br /> Payment TypeCt( g D + Invoice# Check d p2 $O 3 Received By: <br />