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t • <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR �" r / <br /> BILUNG PARTY 0 <br /> FAcum NAME <br /> SITE ADDRESS <br /> �O r r- �nor <br /> Street Number Direction t <br /> SVeef Name TYPe Svlle f <br /> Mailing Address (If Different from Site Address) <br /> Crnr <br /> STATE zip _ <br /> PHONE#1 EXT, <br /> APN# LAND USE APPLICATION# <br /> PHONE#2 [�-oDISTR)CTS. ¢ LOCATION rOOE <br /> v( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR 11 <br /> IU_ eu_uNc PARTY 0 <br /> BUSINESS NAME PHONE# EXT, <br /> 2oq 3`�- 13 <br /> MAILING ADDRESS <br /> >o Bou 2150 FAx# 334- o"?Z3 <br /> CRY // __ 2- <br /> C G) I STATE 0/4 ZIP OiS241 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge Ulal all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly 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 1 have prepared ' application an Ih t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE. -7— — Q <br /> MA � <br /> PROPERTY/BUSINESS OWNER 0 TOR/ NAGER O OTHER AUTHORIZED AGENT c�lJ1rV41 <br /> 1fAnax wr is not tho Bum Pura Proof of authorization to sign Is mqulrvd Ti t to <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,Ute 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 environmental/sile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DlvtsioN 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 /> 3\-)y- �bs�{ <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JUL 17 2007 <br /> rC. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> —'—h ork 1 HEALTH DEPARTMENT <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: <br /> DATE: <br /> ASSIGNED TO: EMPLOYEE 9: <br /> DATE: <br /> Date Service Completed (if already completed): �� <br /> 11 SERVICE CODE: P I E <br /> Fee Amount: t Q Amount Paid Payment Date �1N <br /> Payment Type Invoice#• Check# <br /> 7 Received By: <br />