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� <br />SERVICE REQUEST i. <br />Type of Business or Property <br />GiA50I-1 N E ST'ATI vhl <br />FACILITY ID # <br />SERVICE REQUEST # <br />0 <br />OWNER/ OPERATOR BILLING PARTY)( <br />i c -K 6i61 ZALE�6 <br />FACILITY NAME ?' (^c IG5 G F'v rj O H <br />j` 1't <br />FAX # <br />12 -76S-ICt08 <br />SREADDRESS B Q© <br />Street Number <br />Oirection <br />PAYMCNT <br />L -0 0F—, 1Z �AC�AI��0 �Z? . <br />/'Street Name <br />Type <br />Suite R <br />Mailing Address (If Different from Site Address) <br />CITY <br />STATE ZIP <br />PHONE #1 Ea. <br />(,Zcq) �� �" Oct <br />APN #I .... n <br />0-M,L <br />—7BOS <br />LAND USE APPLICATION # 0 -79 � (, (3_01 <br />C-2 2.006 -1 <br />PHONE #2 Exr• <br />ENVIRONMENTAL HEALTH DIVISION <br />DISTRICT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTER <br />M �4�-l� ��4i, F4�p a,I <br />BILLING PARTY ❑ <br />t� <br />BUSINESS NAME <br />p�IC�h� G�oJ ��.IC. <br />PHONE# EXr• <br />-101Asa �6o Z <br />MAILING ADDRESS <br />HIS -7 11J02 -V MCVdLJF, MV:D- <br />FAX # <br />12 -76S-ICt08 <br />CRY ' IM� STATE <br />C4 LP "t q9� / <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 and that the work to be performed will be done in accordance with ad SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: DATE' <br />PROPERTY/ BUSINESS OWNER Cl OPERATOR/ MANAGER Cl OTHERAtfTH0;ItZE D AG �J `�� ` tk <br />!fAPPLcAmrisnotthe BrtuNG PAary proof o au rtxn to sign is required Title <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 PuBuc HEALTH SERVICES ENVIRONMENTAL 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:lA I_ ` <br />�i <br />n t j L� I��� ' I.1� G <br />l�l'f tJ� / U V Iy ✓ <br />D �i1� ^I %C� <br />�f'�I r� <br />COMMENTS: <br />PAYMCNT <br />RECEIVED <br />JAN 2 01999 <br />BLI J HRAL IN SFRVICV <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />NTRACTOR'S SIGNATURE: <br />i <br />APPROVED BY: <br />ENPLOYw# <br />ASSIGNED T0: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: <br />Amount Paid g. 00 <br />1 Payment Date <br />Payment Type <br />Invoice # <br />Check # I j � S <br />I Received By: <br />