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SERVICE REQUEST <br />9, <br />CONTRACTOR! SERVICE REQUESTOR <br />REQUESTOR BUJNc PARTY O <br />W--,-Z4,�5 <br />K <br />BUSiNEss tLAraEPHORE <br />4-a4W C �./Jii /!,f .T i1G <br />It ocr. <br />MALwG ADoREss <br />1'>� IUr <br />FAX S <br />CtTYe� D Z STATE z►P Qi SZ10 <br />VBILLINIG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorixed agent of same, admawfodgo that aY 3rie and/or projod spedk <br />EALTH SERVICES ENMCtaxwAL HEALTH Dms*N hourlydiarges associated wdh in projectoracgY4 wig be Wed b me ormy business as idenmed on Etas form <br />rdfy that 1 have prepared this application aQd ttwt the rk tube be done in a000rdarrce wPlh all SM JaAaM COXTY Onlinance Codes, Standards, STATE and <br />laws. <br />APruc�u r S"ATURE OA* <br />PROPERTY/BUS94M OWNER ❑ OPERATOR/MMUCAR ❑. OTHERAUTtORMAGxr O <br />rAPruowris raft OLLrypmm yrodda 4wbadw to aitp b rsquirsd Tlth <br />AUTHORIZATION TO RELEASE INFORMATION: When appieable.1. Cw owruror operat"of Cw property located at the above site address. hereby authortne the 1116030 of <br />any and all resulM geotechnical data &Ww wry unmenWsft assossment i ftmadon to ft SAN Jawun Coxm Puauc HEALTH SERVXIS Ernretvrua rAL HE.ALii Onrtsrort as soon <br />as it B available and at Me sauna Ilene it is provided b me or my rep esentagm <br />-7 TYPE OFSERVICEREQUESTED: / i � / I&F7:79,.0 <br />'PAYMENT <br />RECEIVED <br />APR 3 0 2002 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />NVIROWNTAL HEALTH DIVISIO'. <br />APPROvED sy.i / ) DATE <br />AssJGtrEnTo: - vD`L�t1 vE ETrPLOYEE (033 DATE: <br />Date Service Completed •(rf already completed): sammCooE: lg,fl, P!'E 2 3t7b <br />Fee Amount: �� m o Amount Paid-� _ Payment Date <br />Payment Type C �. Invoice # . Check S Received By: <br />9: <br />