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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R ET/�t t G A-5 o c -14 ��'4 3 73� v�2D6 ZS0 o <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> NLAs-t � Ct4kA A Ara (,LF- - �D ¢ A 49 SELL <br /> FACILITY NAME <br /> S � t= L L <br /> SREADORESS `Lt 0 rL 6 L A f`Lt> <br /> C T. <br /> Q Street Number Otredon Street Name <br /> TYPe SvHe l <br /> Mailing Address (If Different from Site Address) <br /> A vw r-- <br /> CITY <br /> CRY STATE ZIP <br /> STO c4ror4 C A 9 SZ lZ <br /> PHONE#1 UT. APN# ; LAND USE APPLICATION# <br /> (2 04) 9 5- - S 3 S 8' 0 cl Z - Z 6 0 -0 <br /> PHONE#2 En. BOS:DISTRICT LOCATION CODE <br /> q If Z 1— <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> 1 C W<1-E L (�(�� (, f 00 rte( . <br /> BUSINESS NAME PHONE# F,r• <br /> l.✓ AFiKK, I-tF-f;2r►[!, . C 916 -3 }3 - /f.S'Z <br /> MAILING ADDRESS FAx# <br /> P. 0 • Bax / 0 2 s' yrb "3 }3 4- <br /> CITY <br /> CtrY <br /> W t--S S �,-c 2 A-ek t� 7-o STATE C A ZIP Cr s 6 9 t <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 /> 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 I have prepared this application a d that the work to be perfo will be done in accordance with all SAN JOAQUIN CotinTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE:--- )- DATE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUiHORIZEDAGENT C0"t-TI'ZA-CA—Vti— <br /> ff Avvt c wr is not ft Reim Pura proof of aurhortzatfon to sign Is requirod Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operatorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION 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: ` �> V L F- (A) <br /> COMMENTS: '` c- 1 c1 PAYMENT <br /> rJ/ J RECEIVED <br /> APR 2 1 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> INSPECTOR'S SIGNA E: CONTRACTORS SIGNATURE: <br /> APPROVED BY EMPLOYEE#: DATE: <br /> �j <br /> ASSIGNED70; EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P!E: — <br /> Fec Amount: Amount Paid Payment Date <br /> Payment Type Invoice#' Check 9 Received By: - %%Zl,14 <br />