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SERVICE REQUEST <br />Type of Business or Property <br />BIWNG PARTY-<­ <br />ARTYn <br />FACILITY ID # OC)SE <br />REQUEST # <br />VICE 53 `00.2 <br />OWNER 1 OPERATOR <br />0 l <br />BILLING PARTY C <br />M l . k <br />lG ?e. .- le c <br />FACILITY NAME 0 S <br />— <br />MAIUNG ADORESS <br />(� iU <br />u <br />66O- -cce- 95 <br />CITY IC— / STATE f�� <br />zip/ -5 7 Q <br />SAN JOAQUIN COUNTY <br />SITE ADDRESS <br />9 k s Street Number <br />oirecton <br />�m <br />(j S e <br />Ty" <br />Suite x <br />Mailing Address (If Different from Site Address) <br />PC, 30 x 9/y <br />APPROVED BY: <br />CITY _ <br />LDi� t <br />STATE ZIP <br />LIE` f,6.`-411 <br />PHONE #1 <br />ETT• , <br />APN # <br />LAND USE APPLICATION # <br />DATE: <br />Date Service Compalrea <br />completed): <br />SERVICE CooE P I E.23 <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />_ <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />BIWNG PARTY-<­ <br />ARTYn <br />--,Ilea & y <br />BUSINESS NAME 4- <br />PHOHO NE # <br />0 l <br />j <br />PAYM E N I <br />FAX # <br />RECEIVED <br />MAIUNG ADORESS <br />(� iU <br />Z61; <br />66O- -cce- 95 <br />CITY IC— / STATE f�� <br />zip/ -5 7 Q <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that ail site and/or project specific <br />Pusuc HEALTH S&zvicEs ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be biped 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 perfanned will be done in accordance with ad SAN JoAQuiN CouNrY Ordinance Codes, Standards, STATE and <br />,APPLICANT <br />DATE: -?—% % _p <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER Cl OTHER AUTHORIZED AGENT ❑ <br />HAva..r wr is not Uie BcLm Paary proof of auftrization to sign is required <br />ride <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1. 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 JOAQUIN 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 />J` <br />COMMENTS: <br />PAYM E N I <br />RECEIVED <br />LIAR 19 2091 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EmpLOYEE`tf: C)6 0 <br />DAT;—:- <br />ASSIGNED T0: <br />ASSIGNED <br />EMPLOYEE# <br />DATE: <br />Date Service Compalrea <br />completed): <br />SERVICE CooE P I E.23 <br />Fee Amount 7� <br />Amount Paid — <br />Payment Date L / <br />1 <br />Payment Type <br />Invoice # <br />Check # <br />32L Received By: <br />n <br />