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L A <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BIWNG PARTY ❑ <br />SERVICE REQUEST # <br />00 <br />P"QNE # <br />f <br />OWNER / OPERATOR <br />BILLING PARTY <br />Pr—, -m -0 o P �t <br />MAJUNG ADDRESS <br />s Y m o0�- - <br />FACILITY NAME <br />q 1:- A'S CAR- Ir>LL�4Si-�► <br />FAX# <br />6t <br />_ <br />��2 <br />CITY S t•� <br />STATE Gi� <br />qU q <br />LP 1 SCJ/ - I <br />SREEA^DO�yRE/S�S <br />U8�1C NZALHEP�IH <br />CL A-2— Street Number <br />l7irecDon <br />Street Name <br />ASSIGNED TO: 7 n C <br />TYD� <br />Suite S <br />Mailing Address (If Different from Site Address) <br />Date Service Completed (if alrdaAy completed): <br />SERVMCODE: <br />C� ` <br />vErr.AP�N# <br />STATE ZIP ��-4— <br />PHONE #i <br />+b) 04� - b 3�0 <br />��- O(oo - �S <br />LAND USE APPLICATION # <br />CSN. 1237-`') -8 <br />PHONE #2 aT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR � 1 V I — <br />`t tL •���� Y <br />BIWNG PARTY ❑ <br />BUSINESS NAME M 1 � _ <br />�\ <br />P"QNE # <br />f <br />EGE�vED <br />MAJUNG ADDRESS <br />s Y m o0�- - <br />FAX# <br />6t <br />_ <br />��2 <br />CITY S t•� <br />STATE Gi� <br />qU q <br />LP 1 SCJ/ - I <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackn wledge that ad site and/or project specific <br />Pueuc HEALTH SERvicEs ENVIRONMENTAL HEALTH ONISION hourly charges associated with this project or activity veill be billed to me or my business as identified on this farm. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with ad SAN JOAQUIN COUNTY Ordinance Codes, Standards, S'A'e and <br />FEDERAL laws. <br />DATE IZ <br />APPLICANT SIGNATURE: <br />PROPERTY I BUSINESS OWNER R OPERATOR I MAMA Cl OTHER AUTHORIZED AGENT ❑ 6"a4xnt <br />II APP,JeWT is not Ire SCLM Pagtt, proof of autttaaation to sign is roVkvd 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 emrironmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONmE TAL 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: i MdU�G �LIS'�- <br />`t tL •���� Y <br />PtPiNv` <br />COMMENTS: <br />Y MEW <br />EGE�vED <br />I;IN OOUN S <br />SpJONQ �jHSER�IpNIS10N <br />U8�1C NZALHEP�IH <br />ENVIRONME <br />INSPECTOR'S SIGNATURE: <br />APPROVED BY: <br />CONTRACTOR'S SIGNATURE: <br />EalPLCYw n`f (� DATE' <br />1EmPLoYEE# <br />ASSIGNED TO: 7 n C <br />� 0 <br />DATE _ 2-7-,120 <br />Date Service Completed (if alrdaAy completed): <br />SERVMCODE: <br />Fee AmountAmount <br />Paid .—(-) <br />Payment Date G� <br />Payment Type I �G — <br />Invoice 4 <br />Check # <br />Received By: ��,� <br />