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• SERVICE REQUEST 0 <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />2ETP.tL �ASo Lr�IE <br />�//�c�O�C� <br />5e2oo -5(OS/� <br />OWNER OPERATOR <br />BILLING PARTY ❑ <br />0 11& < Z --o (P tM A-f?IG ET 5 <br />I I l E Z --- <br />FACILITY NAME <br />u I I/- so P l z %4 <br />SfTEADORESS <br />N - <br />F.0 • BOK /ozs <br />ICK A 14 <br />ST- <br />3}3- /f:) -Z -- <br />SO Street Number <br />Direction <br />zip <br />gs6 � t <br />Street Name <br />Type <br />SuHel <br />Mailing Address (If Different from Site Address) <br />Date Service Completed (if already completed): <br />Ll S- 6 E>f i E2 Pn-r Sr <br />S T _ <br />CITY <br />�fL �tM o,•I-�T <br />STATE zip <br />C A 9 <br />PHONE #1T• <br />APN # <br />Payment Type <br />LAND USE APPLICATION # <br />( $�t0) b s -4 - $ s0 0 <br />Check # <br />Received By: <br />PHONE #2 EXT. <br />BOS.DISTRICT LOCATION CODE. <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />44 t c 64A,t,L V,1A (-Toy( <br />VST 2 G–Z`rzo Fc - <br />BILLING PARTY ❑ <br />BUSINESS NAME <br />PHONE#T• <br />Q, 12- <br />J91643 <br />I I l E Z --- <br />MAILING ADDRESS <br />FAX # <br />F.0 • BOK /ozs <br />INSPECTORS SIGNATURE: <br />916 <br />3}3- /f:) -Z -- <br />CITY Ui S ,A -C fZ Ar f/tAfl <br />STATE C A <br />zip <br />gs6 � t <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 DMSION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application an that the work to be perform will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes, Standards, STATE and <br />FEDERAL IaWS. <br />APPLICANT SIGNATURE: DATE: I Z{ Z y Zo <br />3 <br />PROPERTY/BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C O►LTRAC'�OrL <br />1fAPR,cwrisnotUtee4lrrc)Purry proof of authorization to sign Ismquind Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, t, 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 environmentallsite assessment information to the SAN JOAwN COUNTY Punuc 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 />VST 2 G–Z`rzo Fc - <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />DEC 3 0 2003 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH D PARTMENT <br />INSPECTORS SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVED BY:. O L L 1E4 W -r4 <br />EMPLOYEE <br />j <br />DATE: / ?-/ 3(3 ( 0--?. <br />ASSIGNED TO: �_/ L> +V c <br />EMPLOYEE #: �3 1-7 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: c� Q <br />P I E: 3. ; g <br />Fee Amount: 2_-7 q , c L) <br />Amount Paid i" t: <br />Payment Date <br />Payment Type <br />Invoice #* <br />Check # <br />Received By: <br />IM <br />