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CQP <br /> • SERVICE REQUEST <br /> Type of Business or Property FACT ID r'R CE REQU T <br /> F`foo SERVIods q <br /> OWNER/OPERATOR <br /> Bum PARTY❑ <br /> FAcsm MAE <br /> • SREADDREss'''�/j^/rO � /�Q /; <br /> ` ` �AeMNrmbr pa►tia D , K . T <br /> sats t <br /> Mailing Address (U Different from Site Address) <br /> (:ffY 4.5 STATE ZIP <br /> PHONE NI Exr. APH LAND USE APPLEAMN 0 <br /> PHONE 02 <br /> BOS�DtsTRICT ._. ji'-, �";s;': L.ocAtion.CoDE;=�,<' "•' <br /> CONTRACTOR/SERVICE REOUESTOR <br /> f REQUESTOR <br /> 4�/� NE ffF�✓�E2So BUM PARWE3 <br /> BUSMSS NAME PHONES <br /> MAn.lNO ADDRESS SL 7 N+ FAX 0 <br /> �A2 k E�.J <br /> CITY �+2E•S�Jv STATEzM <br /> G� ?3 7Z,8 <br /> BILLING ACKNOWLEDGEMENT:l the Undersigned property or business owner,operator or authorized agent of same,adVWwledge that all site andla <br /> Pumic HEALTH SERVICES ENVWmxmTAL HEALTH DTVIs10N hmly dmQes associated wb this Project specific <br /> projed•or activity rr�l be t>iGed b me of my business az identified on Clic btm <br /> I also certify that I have prepared tills application and that the work to be performed will be done in ao=dance with all SM JOAOM COUNTY Ordinance Codos,Standards,STATE and <br /> FEDERAL laws. Q <br /> APPUCAtff SIGNATURE:(✓` t" - /`+"6� 7—Z y"od <br /> DAYG <br /> PROPERTY BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OMMAUTHORVEDAGENT ® SZ 2 V/i�C <br /> YAcvucwrls not to @lUJUpNny prvolof suttwkiUon to sign G I*Wkvd Title <br /> AUTHOR17ATION TO RELEASE INFORMATION:When applicable.L Ste owner or operator of the property located at the above site address•hemby autttodza the release of <br /> any and all results•geotc-Chnical data and/or environmenlallsile assessment Womtation b the SAN JOAOM COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DW*N as soon <br /> as it Is available and at the same Gme U is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: T_ , <br /> COMMENTS: 1� <br /> � L� . , (20AYME(\j� <br /> RECENT <br /> EIVED <br /> �U1 2 2000 JUL 2 4 2000 <br /> 0D�NSY <br /> SAN��HaA SH SERVICES SAN JOAOUIN COUNTY <br /> ENTAl IS9 ENVPtRUOBLC HEALTH S <br /> PUBLHEATN DVNMENTAI HEALTH DMS <br /> IDN . <br /> INSPECTOR'S SIGNATURE: ENVIR�NM CONTRACTORS SIGNATURE: <br /> APPROVED BY:. E)APlOYEE 9: 1 DATE: <br /> ASSICNFATO: EMPLOYEES: • DATE: <br /> Date Service Completed (if already complett d�: SERV iI:E CODE: >_ <br /> PIE:: <br /> Fee Amount: 0 Amount Paid <br /> *a3 Payment Date <br /> Payment Type Lt�� � invoice>f' Check 0 <br /> R Received By: <br /> -41 q3 79 <br />