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s. r. <br />0 <br />SERVICE REQUEST EH0061SR revised 09/04/98 <br />FACILITY ID # SERVICE REQUEST #1 tr ik <br />Type of Business or Property 7 <br />BILLING PARTY ❑ <br />OWNEY 1PERAT,OR <br />�- �L� L �%/ V �„�Jc� S►a��ra,rn�vi�' <br />SITE ADDRESS �°� type Suita A <br />t/ /Direetlon Street Nm!e <br />Street Number <br />Mailing Address (If Different from Site Address) <br />f <br />STATE,_ <br />ZIP <br />CnY�/ <br />c� #1 'I ' ✓�' �� Ems• � <br />LAN�UsEAPPLICATIONI USE # <br />LocATION CODE <br />APN # ' <br />PHONE a <br />PHONE#2 EXT. BOS DMcRIt <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REOUESTOR ..,�.- ,.+ � ) � , j�?� G,�-' L�� BILLING PARTY <br />• ry,.�� ter. <br />BUSINESS NAME/ _ i %� � PHOttE # .!s%.i <br />MAn INNG ADDRESS 1 l . S <br />STATE C" ZIP <br />Cm/ �.� L /,•% <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same,, acknowledge that all site <br />and/or project specific PUBLIC HEALTH SERmcEs ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br />me or my business as ident on this form. <br />I also certify that I have p pared this application apd that the work to be performed will be done in accordance with all SAN JOAOUIN COUNTY <br />Ordinance Codes, Stanch .STA and F bEgAL la L� <br />APPLICANT SIGNATURE: '� DATE: j L <br />❑ TOR /MANAGER C] ODER AUTHORIZEDA��� GENT <br />PROPERTY t BUSINESS OWNER T i t l e <br />NAPRJCJWf iS not the an ►nuc; PARTY. proof ofs <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the SAN above site address, <br />he <br />hereby authorize the release ooraNn Eaannd� all HEALTH D geotesIoN h con as it and/orl daavailable and a the environmentatilssa time it is provided to meassessment Information to ormy prese It tive <br />PUBUC HEALTH SERVICES ENVI O <br />TYPE OF SERVICE REtNIESTED: �J /�,� St> ,/�jaC 'r' '/ J 4 a J t <br />COMMENTS ❑ <br />SPECIAL (S) OF JAP` P-ROVAL ❑ OTHER <br />INSPECTOR'S SIGNATURE: <br />APPROVED BY: <br />ASSIGNED TO: <br />Date Service C <br />Fee Amount: <br />Payment Type <br />Invoice <br />CONTRACTOR'S SIGNATURE: <br />Amount Paid <br />EMPLOYEE #: <br />EMPLOYEE #: F <br />2-y-- v <br />Check # ,� <br />C <br />PAYMENT' <br />,er <br />SAN JUAQUIN CUU <br />ENVIRONMENTAL HEALTH SFNV(DIVISION <br />M <br />DATE: V pc <br />DATE: <br />e.3y. PIE: <br />SERVICE CODE: <br />Payment Date <br />af IA/ <br />Received By: <br />Z3`{' <br />