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14 <br />SERVICE REQUEST <br />Type of Business or Property <br />01 <br />BUSINESS NAME+ <br />0t, �j�► r. i li <br />FACILITY ID # <br />MAILING ADDRESS <br />SERVICE REQUEST # <br />167 <br />OWNER I OPERATOR <br />BILLING PARTY <br />FACILITY NAME <br />n� <br />SITE ADDRESS E�� Number <br />Direction <br />,j,�, <br />'� Fr Strait Name <br />DEC 21 1998 <br />Ty"Suite <br />0 <br />Mailing Address (If Different from Site Address) <br />SAN JOAQUIN CuuNTY <br />Cir <br />STATE ZIP <br />PHONE #1 W <br />(� M — 06e� <br />APN # <br />*4— No � <br />LAND USE APPLICATION # <br />PHONE #2 <br />CONTRACTOR'S SIGNATURE: <br />SOS DISTRICT <br />APPROVED BY: <br />LOCATION CODE' <br />CONTRACTOR! SERVICE REQUESTOR <br />REQUESTOR BILLING PARTY ❑ <br />BUSINESS NAME+ <br />0t, �j�► r. i li <br />PHONE# EXT. <br />MAILING ADDRESS <br />FAX # <br />CITY '� STATEZIP ,aN <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that ad site and/or project specific <br />Pueuc HEALTH SERVICES EWRONMENTAL HEALTH DNtSION hourly charges associated with this project or activity will be bided to me or my business as identified on this form. <br />I also certify that I have <br />FEDERAL laws. <br />APPLICANT <br />application and thwgrk to be performed wA be done in accordance With all SAN JOAQUIN COUNTY OrdInence Codes, Standards, STATE and <br />DATE t'116/1'6 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER %IS OTHERAUTHORIZED AGENT <br />If APmr-&hT is rat the 8rtwG Purry proof ofwtlt hkadon ro sign is required <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 environmentadsite assessment infomration to the SAN JOAQuw COUNTY PusuC 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: <br />COMMENTS: <br />PA Y M E N' " <br />RECEIVED <br />DEC 21 1998 <br />SAN JOAQUIN CuuNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVIS10tn <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EMPLOY--#. ��� <br />DATE: <br />'0W <br />ASSIGNED T0:!v �� <br />EMPLOYEE* (/ <br />DATE: <br />Date Service Completed (if already completed <br />SERVICE CODE: <br />P I E:. <br />Fee Amount: >� g r <br />Ifl00 <br />�' <br />Amount PaidV, <br />Payment Date <br />Payment Type Invoice # <br />Check # <br />Q 7 <br />Received By: <br />