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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> moo a � <br /> OWN R OPERA i BILLING PARTY❑ <br /> FACILITY NAME <br /> Im�y r v <br /> ESS <br /> �� / <br /> SITE ADDRESS � '�'f�►�vn�s- 4-GtI7P <br /> StreitNum <br /> ipp, Sutl./ <br /> Mailing Address (If Different from Site Address) <br /> CITYSfi"Aorl . STATE �� <br /> ()43 <br /> ZIP <br /> PHONE#1 r 1 �• APN# LAND USE APPLICATION# <br /> _ <br /> PHONE#2 BOS DISTRICT 1.L, <br /> TION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> I / _m BILL>Hc PARrr�! <br /> BUSINESS LNtAM.• lr0 PHONE# Fxr, <br /> oin <br /> MAILING ADDRESS FAX# <br /> +t <br /> CITY I�Qd 1 STATE A z)P <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 DIVISION hourly charges associated with this projector activity will be billed to me or my business as identified on this form. <br /> I also Certity that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER Cl OTHERAUTHORIZEDAGENT <br /> ItAratx wr is nor rho QuvG PAnrr Prop(or aurhorizaUon ro s ipn is mui vd TRIO <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,gCOtcchnlCal data and/or environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at Elie same time it is provided to me or my representative. <br /> TYPE OF SERVIC[REQUESTED: <br /> Ook,r Oortd Tank Ins eJior� SCA (�/lS <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JUL 2 8 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC ENVIRONMENTALLTH HEALTHVICES <br /> DIV DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. � EMPLOYEE#: 1 <br /> DATE: <br /> ASSIGr{ED 70: EMPLOYEE#: <br /> DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: <br /> PIE:. <br /> ' <br /> Fee Amount: � -6 d <br /> Amount Paid � � p� Payment Date �/�/ <br /> r <br /> Payment Type Invoice# b IN <br /> =h(!Ck <br /> 7✓ Received By: <br />