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SERVICE REQUEST 13 I (� <br /> I YPC of Business or Property <br /> FACILITY ID# ' <br /> / � .�� ' SERVICE REQUEST# �/ <br /> OWNER I OW—VT4R /p ` �! 3 e), <br /> BILLING PARTY 0 <br /> FACIUTI'NAME <br /> r1� <br /> SrrE ADDRESSVa,! mQ �y� Q /� <br /> Str��t Humbfr Wection (� lle <br /> Mailing Addres (If Different from Sile Address) �MHr <br /> Type s�iu I <br /> CITY <br /> f/4— STATE 7Jp <br /> PHONE#1 EXT <br /> ' APN# LAND USE APPUCATION# <br /> -PHONE#2 <br /> ' BOS DLSTRICT LocATa <br /> �hv: N.CODE: <br /> REQUESTO CONTRACTOR/SERVICE REQUESTOR <br /> 1 ^/ BIUING PARTY 0 <br /> BUSINESS NAM- � <br /> PHONE# � <br /> I&LING ADDRESS / p2 <br /> / FAX# <br /> CITY <br /> STATE �p <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property <br /> PuouC HEALTH SERVICES ENVIRCN1IE11TAL HEALTH DmsloN hourly chargesbusiness <br /> with this project orerator raaciivity will beabilled 10gent f mo or my businesss as dentiried on Is forr�rroi. specific <br /> 1 also certify that f have prepared this application and That the we to be performed w <br /> FEDERAL IaWS• ill be done in accordance with all SAN JOAOUIN COUNTY ordinance Codes,Standard:.STATE-and <br /> APPLICANT SIGNATURE: yf�� <br /> DATE:— v 't/d PROPERTYI BUSINESS OWNER 0 OPERATOR/MMIAGER <br /> 0 T}ER AUTHORIZED AGENT <br /> IrAM txwris not Uw n vrry Till <br /> Prooror jurhoriraUon to 3i n is <br /> AUTHORV-ATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the relea e of <br /> any and all resutLs,geotechnical data andlor cnvironmentaUsite ass=mcnt information to UIC SAN JOAWIN COUNTY PUDUC HEALTH SERVICES EtWONMENTAL HEALTH DMStoa as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE Or SERVICE REQUESTED: <br /> (�S T <br /> COMMENTS: <br /> f <br /> PAYMENT <br /> RECEIVED <br /> AUG 15 2002 <br /> SAN JOAOUiN COUNTY <br /> INSPECTOR'S SIGNATURE: PUBLIC HEALTH SERVICES <br /> APPROVED DY:, rr <br /> CONTRACTOR'S SIGNATURE: ENVIRONMFNIYAL HEALTH DIVI410N <br /> CkA.A) �J ( EMPLOYEE 9: <br /> D <br /> Z Z� Z DATE, <br /> L <br /> Gly ,/t EMPLo'rEEH <br /> D L DATE: <br /> cc (if already con1Plrtedl; _—T <br /> Fee Amour,,: - <br /> LL,. Amount Paid Payment Date <br /> PaymcntType <br /> Invoice h' Check U <br /> Received By: <br />