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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rzE-TA,IL C; Ar-so LfiltF, SACC 33 ?0-2— <br /> OWNER <br /> 0'ZOWNER I OPERATOR BILLING PARTY❑ <br /> �2 F-4> e s F*—It*)1 a-n.y <br /> FACILITY NAME <br /> IM R - C Ar F r <br /> STTEADDRESS _ L '1> p Q- A-p O <br /> I Street Number okection I streetNnne ITF- Suit.1 <br /> Mailing Address (If Different from Site Address) <br /> Ito 1 2t A-KKLK- C-T- - <br /> CrTY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (yo$) 0 -4 - 8-3 c, 13`I — CSZ - 0� <br /> PHONE#2 ExT• BOS:DISTRICT LOCATION CODE . <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> Wil I c t+��L �A L -7-0�t <br /> BUSINESS NAME PHONE# EXT. <br /> W A L,TO f-4 C tic C 141=itL rL.r-L f, , �� c <br /> MAILING ADDRESS FAX# <br /> �. 0 • Qo X f oZS �Ic 3�-3 — Il � z <br /> CITY r I I <br /> W - h'L Z p,- WL F-"-,r-o STATE C A, ZIP �S-6 Q ( <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge Itiat all site and/or project spe iric <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsION 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 and that the work to be performed will be done in accordance with all SAN JoAwN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: 1 t N A-64- WA,L.roti DATE: S�l r!t 3 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT >;6 CC U-T-IZ ACT-0 rL- <br /> If Aavtcwrisnotft6 LrrcFum proof ofruthoruatlontosign Isrequirod Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authcrize the release of <br /> any and all results,geotechnical data and/or environmental Bile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENvi toNMENTAL HEALTH Dr VISION 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: �� S r Pr L L 41••IQ wf -P L A-1 C 0-E C tL <br /> COMMENTS: <br /> PM <br /> 5!,BIJC Hui TH`� �LclCtt� <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: 1��' DATE: ✓ _Q 3 <br /> ASSIGNEOTO: ` 4 EMPLOYEE 9: G� DATE: (l� <br /> Date Service Completed (if already completed): ! SERVICE CODE: <br /> Fee Amount: ('Z Amount Paid tj -1 _ Payment Date <br /> Payment Type L, Invoice# Check# j Z ZZ Received By: � <br />