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V <br />0 0 <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BILLINGpARn�( <br />SERVICE REQUEST # <br />`2ETNtc CP-5,0L(nte- <br />FA-0003rZz <br />BUSINESS NAME <br />S120G✓a'�Q- S� <br />OWNER OPERATOR <br />BILLING PARTY ❑ <br />Q U I S TO P W1 Ara- V -E -`TT s <br />PAYMENT <br />FACILITY NAME <br />Q�tIL Srto� '4 138 <br />r�s2— <br />SITE ADDRESS <br />L( k C 0 L P( <br />DEC 18 2003 <br />P•0• 'Roy, /O ZS- <br />/I S 3 Street Number <br />Direction <br />SVM Nam. <br />STATE C Q zip <br />Type <br />saner <br />Mailing Address (If Different from Site Address) <br />ASSIGNEDTO: J (r / <br />F*LrS41-Pr,tS ST - <br />1 DATE: j 2•• (k 03 <br />CITY � <br />tZEvtioKT <br />STATE C A zip <br />9%5-38 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(�10) F -s00 <br />Payment Date <br />Payment TypeG �� <br />PHONE #2 EXT. <br />BOS:DISTRICT <br />LOCATION CODE: <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />BILLINGpARn�( <br />Y r l 1 C 6( Ar !r L WAL "r0 ►-i <br />BUSINESS NAME <br />PHONE#• <br />AC'i✓o►( E�tr.t�tr%�rLIA4 :r7;4C - <br />PAYMENT <br />q16 <br />r�s2— <br />MAILING ADDRESS <br />FAX # <br />DEC 18 2003 <br />P•0• 'Roy, /O ZS- <br />qf6 -333-(t-4Z <br />INSPECTORS SIGNATURE: <br />CITY ( <br />S �-f. 2 A � �-.�-o <br />STATE C Q zip <br />9 5- 6 4 <br />BILLING ACKNOWLEDGEMENT: 1, 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 cerdt that I have prepared this applicad and that the work to be pedo ed will be done in accordance with all SAN JoAOUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL. laws. <br />APPLICANT SIGNATURE: DATE: 2- Ar /0 3 <br />I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT V C 101-LT-fZ A C-i—O /ice <br />II Anaucwr is not fhe B,urrc PARrr proof of anthoruatlon to sign Is nequlrvd 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 environmentallsile assessment information to the SAN JOACUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION 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 />(�L=j <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />DEC 18 2003 <br />N JOAOUIN COL1N <br />INSPECTORS SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />EA P <br />H <br />APPROVED BY:.0 L I �� 1 � <br />EMPLOYEE #: 03 � <br />ATE: <br />ASSIGNEDTO: J (r / <br />EMPLOYEE 9:7 3 ,?o <br />1 DATE: j 2•• (k 03 <br />Date Service Completed (if already completed): <br />SERVICE CODE: Ci <br />P f E:�3 6�' <br />Fee Amount: c)-7 c/o r, <br />Amount Paid- <br />Payment Date <br />Payment TypeG �� <br />Invoice t#' <br />Check # — <br />Received By: -n <br />L <br />I aC <br />