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SERVICE REQUEST • <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �s �9 <br /> OWNER I OPERATORnn JJ II BILLING PARTY[IDE ln�>' or' C4uFD2nroNig <br /> FaclLrnr NAME <br /> UP - S.6c.� -6n <br /> SITE ADDRESS pn Dp/����.,(/)) S /�d-,Ar r Qo� / <br /> 33d .oar f^'"`r'e'SlreetNumbar oiretCon /t SV(M/N\xne L!TY(—,— <br /> Mailing <br /> � SuHe/ <br /> Address (If Different from Site Address) <br /> CITY <br /> CA- <br /> 47& STATE ZIP re �O <br /> CA <br /> PHONE#1 �• APN# LAND USE APPLICATION# ` <br /> ( <br /> PHONE#2 Exr• BOS DlsrRlcT <br /> LOCATION,CoDE <br /> i <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> C (---- <br /> rn CJ BILLINGPARrY,t <br /> BUSINESS E� v , , /• � PHON # Fxr. <br /> 'h J poi sty- �c�53 <br /> MAILING ADDRESS FAX# <br /> 9 -.Z 0 SO <br /> CITY n/1/1D,a"Z T— O STATE Cn_ 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 prepared this application th a work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. r J <br /> APPLICANT SIGNATURE: I til DATE:--VI / /allU-7) <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT )d 6 ISIS�r C Fb-1 <br /> If Anmxmr is not the BrtinvG Panry proof of authorization to sign is requirvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBUc HEALTH SERVICES ENVIRONMENTAL HEALTH DivlsloN 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: /7 An <br /> COMMENTS: <br /> APR 2 6 2000 <br /> ',AN JOO^I! <br /> PVNLJC HE�T <br /> ENVIRONMENTAL <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: I DATE: <br /> ASSIGNEDTO: EMPLOYEE Ci DATE: <br /> Date Service Completed (if already c leted): <br /> SERVICE CoDE: pE; /1 <br /> v` V <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice#' Check 9 Received By: " <br />