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' . <br /> SERVICE REQUEST 40 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R0034- ► IZ <br /> OWNER/OPERATOR �/��, BILLING PARTY <br /> /ZC LC Z <br /> FACILITY NAME <br /> SIT EADDRESS SIM Nu.,I. G01rectian / / n // <br /> SVMNxm TYD� Sultil <br /> Mailing Address (If Different from Site Address) Ail <br /> CITY6C-O STATE /�� LP Gr�yr�� <br /> PHONE#1 APN# LAND USE/ <br /> USSEE APPLICATION# O J C� <br /> ( ) <br /> PHSNE#2 BOIS;DIsiR1CT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS!!�Fy Aj PHONE# Ext. <br /> MAILING ADDRESS <br /> Fax <br /> CITY &LIl � STATE rY ZIP <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 I have prepa this application a that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> WPPLICANT SIGNATURE: DATE: <br /> ROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IIAaDUGavc <br /> ,wrisnotft6i PA/iTT pmofolauthorivationtosign Isrequi 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 environmentallsite assessment information to the SAN JOAQUIN 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: j ]1 <br /> COMMENTS: �J <br /> V�ECEJ\Ec) <br /> SUN 5 2003 <br /> . oAou1N sERvicEs <br /> ENV RONMENIAL�HEALTN OI�ISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. VIM EMPLOYEE#: -1 Y DATE: <br /> ASSIGNED TO: EMPLOYEE 9: `{� D DATE: <br /> (0 <br /> Date <br /> 3 <br /> Date Service Completed (if already completed): u SERVICE CODE: PIE; 2 Q <br /> Jq 00 <br /> Fee Amount: <br /> mol Amount Paid Payment Date <br /> Sa 3 <br /> Payment Type Invoice>#' Check 9 Lt( S Received By: �� <br />