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0 <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />MAILING ADDRESS — 1 <br />( (` UIQ, <br />_ <br />OWNER OPERATOR <br />BILLING PARTY ❑ <br />FACILITY NAME <br />SITE ADDRESS <br />� <br />ENVIRONMENTAL HEALTH DIVISION <br />UStreit Number <br />DirectionK <br />/' j�� <br />SV�rrNam� <br />TP, <br />Solt. J <br />Mailing Address (If Different from Site Address) <br />DATE: <br />l O <br />C ' <br />ST E ZIP <br />PHONE91 Er. <br />APN # <br />LAND USE APPLICATION # <br />:Date Service Completed (if already completed): <br />SERVICE CODE: <br />PHONE #2 <br />BOS:DIsTRicr <br />::. . <br />LocATaN.CoDE _.. :'• <br />CONTRACTOR I SERVICE REOt1FSTOR <br />REQUESTOR/ BIWNG PARTY CI <br />BUSINESS NAME <br />1 q <br />PHONE#EXT. <br />2 <br />MAILING ADDRESS — 1 <br />( (` UIQ, <br />FAX <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge Uiat all site and/or project specific <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Drns:0tt hourly charges associated with this projector activity will be billed to mo or my business as identified on IhIs form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with aft SAN JOAQUIN COUNTY Ordinanco Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE:- .2 Ct I%L�-(�1 Its— OATS: <br />PROPERTY/ BUSINESS OVrNER ❑ OPERATOR MANAGER ❑ OTHERAUTHOrzizED AGENT ❑ <br />ff APPLc wr is not Ub P4 M f Amy,, proof of authorizatlon to sign is roQuirod ri t t o <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 andfor environmental1sile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SEFMCES ENVIRONMENTAL HEALTH Dmsiw as soon <br />as it is available and at the same time itis provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: fj <br />COMMENTS:i,�%�� te� t^=/t 0 9 r %�r �Sz)-Y� <br />t <br />PAYMENT <br />RECEIVED <br />AUG 2 0 2001 <br />SAN JOAOI.'IN COUNTY <br />PUBLIC <br />HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. <br />EMPLOYEE �+� �D <br />J <br />DATE: <br />l O <br />ASSIGNED <br />r. <br />EMPLOYEE _ 3 \ &0 <br />DATE: <br />v <br />o <br />:Date Service Completed (if already completed): <br />SERVICE CODE: <br />'/ - <br />p.! E,3 0 <br />Fee Amount: <br />Amount Paid <br />61�0Payment <br />Date <br />'3 20 01 <br />Payment Type Invoice It' <br />Check,f� I <br />�b <br />Received By:� <br />