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0 SERVICE REQUEST 0 <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />TZET-A►L .46-S0LItLFs <br />F� <br />e)(2n <br />Q 3 (n5 <br />OWNER I OPERATOR <br />BILUNG PARTY ❑ <br />U t I& S T 0 p 1M A-2 IL Ff-(- S <br />(,ti Pti L't' nc <. I �c C, F— rZ r �< <. <br />FACILITY NAME <br />(t 6) 3 3— <br />SITE ADDRESS <br />MAILING ADDRESS <br />E S T <br />L <br />C • BOX /o Z5— <br />1 <br />Z T 2/ Street Number <br />Olrecton <br />1r4Z <br />SVMNxno <br />Typa <br />Suke/ <br />Mailing Address (If Different from Site Address) <br />APPROVED BY:. �j [ -f tlE f eA <br />S -} E ►c TER tL t S tz ST _ <br />EMPLOYEE #: ?� �' <br />Crnr <br />Ft2Gwto►�T <br />STATE zip <br />C� �1yS3 � <br />PHONE # i <br />APN # <br />DATE: rZ 3v <br />LAND USE APPLICATION # <br />(Sro) (o s�- 8•soo <br />SERVICE CODE: (j <br />PIE: �?--? <br />Fee Amount: -'I <br />PHONE fit Err. <br />Payment Date <br />PBOS DISTRICT LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />r <br />BILLING PARTY' <br />Wl I C 6( A- E L W A I-1—c)r( <br />BUSINESS NAME <br />PAYMENT <br />PHONE# <br />EXT. <br />(,ti Pti L't' nc <. I �c C, F— rZ r �< <. <br />�..� C_ <br />(t 6) 3 3— <br />r r s -2 -- <br />LMAILING <br />MAILING ADDRESS <br />FAX # <br />C • BOX /o Z5— <br />ENV RON NTAL <br />9'r -s <br />1r4Z <br />CITYVN �� <br />� • 1 - J ' 2 �A- �iN.%��O <br />STATE CA zip <br />2 S-6 4 1 <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 DrnsloN 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 an) that the work to be <br />FEDERAL laws. <br />APPLICANT SIGNATURE: <br />will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />DATE: 1 2, 1 11 /Q 3 <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 'R( C C)AtTR A -C If -C L - <br />If AppLGwr is not the B&Lm proof of authorivadon to sign is requlrvd 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 environmental/Stte assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENvrRoNMENTAL 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 />r <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />DEC 3 0 2003 <br />SAN JOAQUI COUNTY <br />ENV RON NTAL <br />H D T NT <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. �j [ -f tlE f eA <br />EMPLOYEE #: ?� �' <br />DATE: 1 2-13 t1 I G'3 <br />ASSIGNED TO: <br />L' <br />EMPLOYEE 9: <br />DATE: rZ 3v <br />Date Service Completed (if already completed): <br />SERVICE CODE: (j <br />PIE: �?--? <br />Fee Amount: -'I <br />Amount Paid 101)- <br />Payment Date <br />Payment Type Invoice #' <br />Check #(3,351 3 -1;1 <br />Received By: <br />