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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPEP.kTOR BILLING PARTY 0 <br /> FACILITY NAME '<1 S J <br /> SITE ADDRESS /'''�) <br /> Street Number Oirectioe tom( •"' Sveat Nun. Type —S.-He I <br /> Mailing Address (If Different from Site Address) <br /> CITY a STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 <br /> ExT. BOS DISTRticr LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> BUSINESS NAME PHONE# Err. <br /> /G—Z✓c� �.� r"cp,�si�Xa.e f`�r:� c g i 4 3 5-0 s- 1!& <br /> MAILING ADDRESS FAX# <br /> .20 `1113 <br /> CITY � 7—a = `� STATE �-g Z)Pv <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 project or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordnance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT ❑ <br /> If APaucaNT is not the BntwG PAKTY proof of auft&adon to sign is required 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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OmsION 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: 6—,-Ir/57/A�1j )::-e7 I-z— of tAJ �— .�/� 6P111 ry <br /> P /'— 11.5 /S 64 //o .,� ��•%/ ��C- <br /> 0 !� FS <br /> 1�JC�dES� r � C 13rAt; Cc'2b 4c,✓�,-cJ <br /> IPAYNIE <br /> RECEIVED <br /> DEC 910 <br /> SAN JOAQUIN COUNTY <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: PUBLIC HEALTH SERVICES <br /> APPROVED BY:. EMPLOYEE#: (��) DATANVIHQNM: AL ISION <br /> ASSIGNED TO: EMPLOYEE#: o C/ DATE: Z G <br /> Date Service Completed (if already completed): SERVICECODE: ( P/E: 23d <br /> Fee Amount: 3 Amount Paid $02 3 L/ _ Payment Date ('x/y 4 9 <br /> Payment Type Invoice#' Check# /S Received By: <br />