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SERVICE REQUEST • <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �. 000zz3 2 Z.7 ZIL <br /> BILLING PARTY❑ <br /> OWNER I OPERATOR <br /> Q I K JTdP <br /> FACILITY NAME <br /> t la J <br /> SITE ADDRESS f[INA ---vt LA-f. <br /> 3555 streNNumher Direction Street Name Type Suite: <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> CITY <br /> PHONE#1 �*• APN# LARD USE APPLICATION# <br /> ( ) <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONT RACTOR I SERVICE REQUESTOR <br /> BILING PARTY❑ <br /> REQUESTOR <br /> PHONE# Err.NAME <br /> y D-�-CaZ•t7 <br /> MAILING ADDRESS FAx# <br /> 2 <br /> CITY STATE C-A- Z1P 9 rsO <br /> v <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 DNISION 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 appfication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> DATE' <br /> APPLICANT SIGNATURE: <br /> PROPERTY/BUSINESS OWNER C OPERATOR/MANAGER ❑ OTHER AUTHOR[ZEDAGENT C title <br /> If APPLC.Wr is not the Bit <br /> MG Pnary proof of authorization tO sign is regdved <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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EYVIRONMENTAL HEALTH DIVISION 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: 12 Leo4c <br /> 1 <br /> COMMENTS: <br /> JOg172001 <br /> , <br /> V�n�pAFNTy <br /> T L "V�. ERV <br /> ENIE ON <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: FmpwYa#: OC` DATE' ol, Q <br /> ASSIGNED T0: IG. EMPLOYEE#: 6 DATE: <br /> SERVICE CODE: n _ •P <br /> Date Service Complet (if already Completed): /V/01/01 <br /> ` <br /> Fee Amount: Amount Paid /I Payment Date <br /> Payment Type Invoice# Check# Received Sys-- <br />