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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �o�vsnuac 17aX) 19, c)-a-0C1�I (A Cl <br /> OWNER/OPERATOR BILLING PARTY <br /> 406-57- <br /> � i�G - DSS CoiU_<71C?7d� <br /> FACILITY NAME P c CS771—e�'/77��J <br /> SITE ADDRESS / //V'� �/ <br /> (� S"d Numbr Dimon —S3at NMO Typ- suiU 0 <br /> Mailing Address (If Different from Site A dress) �lSZ <br /> o - x <br /> CITY G/'� J.,�, l STATE ZIP <br /> H N M r�20 Err. APN# LANG USE APPLICATION# <br /> PHONE#2 �• BOS DISTRICT LOCATpN CODE:; <br /> CONTRACTOR i SERVICE REQUESTOR <br /> REQUEs OR ^ BILLING PARTY❑ <br /> Apv-f� 6160 <br /> BUSINESS NAME / U T M4�r�' PHON 7— Ea.l0 UDS 46— <br /> MAILING ORES <br /> �' CJ(L�Q�v FAX# 7_///1�J <br /> CRY -112' STATE /�_ ZIP '?S'26,5— <br /> J <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same, acknowledge that ad site and/or project specific <br /> PuBLIC HEALTH SERVICEs ENVIRONMENTAL HEALTH DmsioN hourly charges associated with this project or ach*YAH be billed to me or my business as identified on this form. <br /> 1 also certify that I have preps plication an al.ft wvrk to be performed be done in accordance with ad SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: j DATE:- <br /> PROPERTY/ <br /> ATE:PROPERTY/BUSINESS OWNER O OPERATOR!MANAGER OTHERAUTHORRED AGENT Ipa�^""�� GUCTG!/PY�17S 5 <br /> IfAAw rawris nd theSttRrcPur►v prod of WdMizadon to sign is req Ared 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 arKi/or environmentallsite assessment information to the SAN JoAQuw COUNTY PUBLIC 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 /> COMMENTS: <br /> PAYMENT <br /> DEC 9 9 8 79'�E <br /> RUSMVIR <br /> 9� <br /> SAN JOAQUIN COUNTY � PERMIT/SERVICES <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> S <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOY--#: DATE: <br /> ASSIGNED To: EMPLOYEE#: G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �L4 <br /> PIE: <br /> Fee Amount: ?j Amount Paid Payment DateZo <br /> Received By: <br /> Payment Type Invoice# Check# 1 <br />