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— <br /> SERVICE REQUEST <br /> +Tjrpe o[Business or Property ' FACUTY ID 8 SERVICE EGUEST <br /> _ L510 I <br /> W OWUMI OPERATORBILLING PARTY <br /> F .G <br /> FAcun NAIVE �7 <br /> L o U <br /> StrEADDRESS 50 Lpt�gry l C�dy�'\`t3 <br /> Str-W-w Oinetlen t� Nami T S�rile s <br /> Mailing Address (If Different from Site Address) <br /> 71 VAS- e e, <br /> CITY TE ZIP <br /> )AST NO a <br /> PHONE#S Ext APN# LAND USE APPLICATION# <br /> (110d) 7� -7 C <br /> PHONE#Z 1 IST <br /> S:OUESTOR DRICT LOCATION CODE <br /> CONTRACTOR ISERVICE <br /> REOUESTOR BILLING PAM 0 <br /> ,r• e <br /> BUSINESS NAME PHONE# Err. <br /> 7 0o b <br /> MAILING ADDRESS FAx# <br /> CITY , • -r) STATE ZW <br /> V00; (1911 7 <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner,operator or authorized agent of same, acknowledge Mal at she and/or project specific <br /> PUBUc HEALTH SERvrCEs ENmoNMEMAL HEALTH Dmsm hourly charges assaaated with this project or activity WM be bated to me or my business as identified an this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in i ccordance with all SAN JOAW N COUNTY Oelnance Codes.Stsnderds,STATE and <br /> FEDERAL laws. f <br /> APPLICANT SIGNATURE' ~ C. DATE: C> G�G ytv l <br /> PROPERTY/SUSNESSOWNER Q OPERATOR1MANAGER ❑ 01HE AUTHORIZED AGENT .STA�7 rz�?l <br /> Ir✓ .t�-- <br /> rAPP. T is rd the At,PC PAar�Proof f avowtatlm to sign b nqu Tr1 TWO <br /> AUTHORIZATION TO RELEASE INFORMATION:When appricable,L the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and at resutis,geotechnical data and/or environmentalrsite assessment information to the SAN jQAOU1N COUNTY PUBUC HEALTH SERvICES ENVIRoNur-NtAL HEALTH DmsION as soon <br /> as ti is available and at the some time R B provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ! 1 C.r—T— f� rj <br /> COMMENTS: <br /> PAYMENT <br /> PECEWFTI <br /> AUG 2 8 1998 <br /> SAN JOAOUIN CUBAN rY <br /> PUBLIC HEALTx SEWjrES <br /> ENVIRONMENTAL HEALTm DrVISION <br /> INSPECTOR'S SIGNATURE: CORMC70 'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: I. DATE: <br /> ASSIGNEDTO: ( Y EMPLOYEE#: © OS DATE: Z <br /> CO <br /> Date Service Completed (if alr ady completed): SERVICE CODE: O*3Zq P f E6 30 <br /> FeeAmountil (P r (� 1. <br /> Amount Paid Payment DateOCD <br /> Payment Type Invoice 0 Check# Received Sr. <br />