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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It <br /> SERV pt <br /> rzW 0 a <br /> Ovr/fE�/OPI;RArOR � 7 <br /> BwNG P <br /> • FACILITY N.wE <br /> StnKN�eibr Orrrctbn StrMlrahur 'yp. Sdh.f <br /> Mail) g Addr ss !f Different from Site Address) <br /> v95,2207 <br /> CITY STATE ZIP <br /> PHONE 1 EXt. APN 9LAND UsE APPuCATTON Ill <br /> j .PHONE 92 <br /> ren. BOS.DaTRIGT LOG1T101i.CooE' <br /> CONTRACTORI SERVICE REQUESTOR <br /> REQUESTOR r al.LM PARTY O <br /> �►- ���:�{Z-1'S l-� - �©moi S <br /> BusrruEssNAace PHONtaif� <br /> WrtmG ADDRESS FAX# <br /> �- i WI -57 <br /> CrSY �� STATE Zip <br /> BILLING ACKNOWLEDGEMENT:L me undersigned property or business owner,operator or authorized agent of same,acknowledge Mal all sde and/or project specific <br /> PuKx HEALTH SaIVICES ENVRO maiTAL HEALTH ON ISION hourly charges assokiatec;with this projector acivity will be Wed to me or my business as iden6iied on Ods farm <br /> I also certify that I have prepared fts appflca5an and that the work to be perfomhed will'he done it aenordanoe with al!SAN J09M CWnY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. <br /> t f, , 4r� <br /> APPLICANT StGNATTJR � 1l �Ll�i t , <br /> �' - a*� DATE: <br /> PROPERTY/BUSINESS OWNER O OPERATOR/M WAR O OTWMAUnimzEDAGENT O <br /> DAinrw,is not It*fiLIfS88=prwr oIxrlhadurron ro sign is rwuW rill# <br /> LITHO t7AT1 N TO RELEASE INFORMATION:When applkabie.L the owner or operator of the property located at the above sHo address,hereby au0arim the release of <br /> any and al resutts,geotechnical data and/or environmentalfstle as::essment InfomhaWn b IN SAN JOAOUN COUNTY PUGM HEALTH SDIVIC0 ENVIRONMENTAL HEALTH D NMtW as soon <br /> as it Is avakitable and at the Sarno time It is provided to me or nhy:epmsenta6m <br /> TYPE OF SERVICE REgUESTED: <br /> cdlukEtrrs: V?V'd-D C4rhrl &e b s <br /> .. PAYMENT PAYMENT <br /> f uz4�t ait�v R-+f41IL +-b RECEIVED <br /> G✓.�f �i�� A#0-2- -x Fro' L-4 • SEP 2 2 2000 <br /> SAN JOAQUIN COUNTY <br /> ENMRQ"CC--NTAI-HEALALM TH SERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED DY:. � EASPLOYEE O; <br /> DATE: <br /> ASSIGNED T0: ENPLAYSE 9: <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CoOE <br /> PIE: 7 <br /> Fee Arnount: �- Amount Paid <br /> :iilii!674 Payment Date <br /> Payment Type Invoice rf' Check II <br /> ,3 Received I3 . <br />