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I <br />of Business or Property <br />SERVICE REQUEST <br />FACILITY ID # <br />0 <br />SERVICE REQUEST # <br />331 <br />BtwNc P <br />:R I OPERATORn4,a 1Li <br />ny NAME <br />'/ADDRESS <br />Sweat Number OtraCion Type surto a <br />ng Address (If Different from Site Address) <br />CITY =tcei <br />7 -f <br />PbgNE 1 <br />p <br />Err. APN# LAND USE APPLICATION# <br />PHONE #2 Err. BOS DtsTRfcr L.acATION COOS <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY 0 <br />BUSINESS NAME, PN NE# <br />live// iti�P��� /1� C S 3 <br />MAllJNGASF FAx r— 111 <br />Cay STATE <br />�y STATE C/4— Z"P qS� 76 j <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sde andlor project specific <br />PUBLIC HEALTH SERVICES EwnoNmENTAL HEALTH DIVISION hourly charges associated with this projector acJv* will be biped to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be perfamhed wig be done in accordance with ad SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. J <br />APPLICANT SIGNATURE: DATE: �T Z, <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR I MANAGEROTHER AUTHORRED AGENT 0 <br />NAPPLCANr s net fhe 9+Lac Pura proa of a awiuBon to sign is rKucnd 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 anillor enV=nmenfalfsite assessment information to the SAN JOAQuN COUNTY Pust.ic HEALTH SERVICES EwRONAIENTAL HEALTH DmSiON as soon <br />ae k is avni nhip anrd at the same time it i5 provided iD me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />�ll h S jJ <br />i i r C�` <br />COMMENTS: <br />PAYMENT' <br />RECEIVED <br />-SEP' 42002 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CoNTRACrOR'S SIGNATURE: <br />APPROVED BY: <br />Emn-am I S <br />BATE: <br />ASSIGNED TO: <br />8 r1j)-� <br />EmnoYEE#- S 3 g <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E. Z 3 d <br />Fee Amount: <br />-7 <br />Amount Paid <br />Payment Date r ; <br />Payment Type <br />Invoice # <br />Check # <br />I O &5_1 <br />179 <br />Received By: <br />