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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> BILLING PARTY 0 <br /> OWNER 1 OPERATOR <br /> ISA L,4S r ! � CfI r} CA Molir <br /> FACILITY NAME t S , I� L� <br /> SITE ADDRESS7 00 lAn�n� L� <br /> Sind Numbr Ofnction ,�"/ SVtd Hum Type Sulu <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP -L 1 Z <br /> CITY S'i F)C ft's J� <br /> PHONE#1 PN# LAUD USE APPLICATION# <br /> (7 01) c] IN - 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> BILLING PARTY❑ <br /> REQUESTOR <br /> BUSINESS NAME PHONE# UT' <br /> (.vim r NE ��Y Iii <br /> Ma <br /> AILING ADDRESS U j^^ l-7 <br /> 7 rQ y J r l F 94 4 ` rp]y 6 <br /> CITY SI'IGQ1 '' `Vl rfA y�f{ r� STATE G LSP 7 SS 3 a <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknawtedge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 appficalion and that the work to be performed will be done in accordance with aA SAN JOAQUIN COUNTY ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: G <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR t MANAGER OTHER AUTHORao AGENT ❑ �� .S� � <br /> It APDL.WT s not the BUNG p urr� Proof of audrodudon to sign 1s nquirW Title <br /> AUTHORIZATION 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 results,geotechnical data and/or envlronmentaVSite assessment information to the SAN JOAQUw COUNTY PUBLIC 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 REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> �- RECEIVED <br /> AUG2 <br /> SAN JOAQUIN COUNT'T <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONNIENYAL HEALTH[)IVISIOI� <br /> INSPECTOR'S SIGNATURE:. CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEEI DATE' S2 � <br /> ASSIGNED TO'�. �j i ��r r r(.� EMPLOYEE#: 'c DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: P f E:. <br /> Fee Amount: Amount Paid Payment Date <br /> FPayment Type Invoice# Check# R ceived By: <br />