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SERVICE REQUEST <br /> Type of Business or Property FACILITY IDM SERVICE REQUEST M <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> FACILfTy NAME <br /> SITEADORESS <br /> Sven Nunn O(rtci;on rnTry SLLto l <br /> Mailing Address (If Different from Site Address) <br /> CITY l STATE ^ ZIP <br /> PHONE'#1 APN M LAND USELAPPLICATION# <br /> ( <br /> PHONE M2 BIDS DISTRICTLOCATION CODE. <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTORIT Hu1>rrQPA,ci <br /> BUSINESS NAME 1 1 PHONE# aT• <br /> 1 t1`� b�S►6� ti�bU� r ANG - 101 oto `11p(0 � <br /> MAtuNG ADDRESS FAX# <br /> 113 Wt�ot�t<u ��,vn . 7u1 1e5- aG o 8 <br /> CITY �VF Th L.1AWtA STATE 6A ZIP q�� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that ad site and/or projed specific <br /> Pueuc HEALTH SERvicEs ENVIRONMENTAL HEALTH ONIsION hourty charges associated with this projector activity will be billed 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 performed wig be done in accordance with ad SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. 1n\' } I <br /> APPLICANT SIGNATURE: YIU� DATE: 1 I12� //U�o� I <br /> PROPERTY/BUSINESS OWNER Cl OPERATOR/MAMGER 0 OTHERAu HoRREDAGENT VO'J C^ I ki 9 <br /> It APPUowr is nd the BxLm PNrr r proof of suthortrstlon to sign is rvWxW Ti tl e <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=Jlor environmentallsite assessment information to the SAH JOAQUIN COUNTY PUBLIC HEALTH SERv10`S EwRoNmENraL HEALTH DwION 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 /> e <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: '/— EstPL t DATE: <br /> ASSIGNED TO: EMPLOYEE#: 1LJ DATE: <br /> Date Service Complet4 (ff alreacq completed): SERvim CODE: P IE:. �, <br /> Fee Amount: / � - Amount Paid �a 3 v Payment Date 9 <br /> Payment Type Invoice 4 Check# O/ Received By: L <br />