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Ia <br />0 SERVICE REQUEST • <br />e ofBusin s r Property <br />IINESS NAAI ;n /J } <br />r <br />ID # <br />LING ADD ESS � IA %r y� Q <br />SERVICE REQUEST # <br />Y STATE <br />JFACILITY <br />-aa) <br />PAYN9 LN'! <br />VE 1.0E T <br />0 <br />RE0tIs FI-.-' <br />BILLING PARTY ❑ <br />��( A 0- C/ <br />JAN . ° 9 2002 <br />ILITY <br />SAN JOAOUIP; •. _ .; <br />ADDRESS <br />j, <br />WARONMFNTa <br />INSPECTORS SIGNATURE: <br />( <br />LMeecon <br />LO <br />EMPLOYEE <br />FSuRlf <br />1 Strut Number <br />-4'' 6112 <br />StrW Nang <br />TYPE <br />Date Service Completed (if already completed): <br />ling Address (If Different from Site Address) <br />SERVICE CODE: <br />P / E: <br />Fee Amount:Amount <br />`ice <br />Paid <br />STATE Z1P <br />EXT. <br />APN # <br />Invo #' <br />LAND USE APPLICATION # <br />0 �oZ�p tC� <br />S `� 33 <br />Received By: <br />NE #2 <br />BOS,DLSTRICT LOCATION CODE:. <br />CONTRACTOR 1 SERVICE REQUESTOR <br />IUESTOR BILLING PARTY <br />IINESS NAAI ;n /J } <br />r <br />PNONE #� / r <br />LING ADD ESS � IA %r y� Q <br />,AX # <br />Y STATE <br />e ZIP <br />LIC HEALTH SERVICES <br />o certify that I have <br />ERAL laws. <br />'LICANT SIGNATURE: <br />ENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that an site and/or project specific <br />MENTAL HEALTH DMSION hourly charges associated with this projector activity will be billed tome or my business as identified on this form. <br />this application and Ihat oris to be perfo will be done in accordance with all SAN JOAQUIN COUNTY Ord* co Codes, Standards, STATE and <br />)PARTY/ BUSINESS OWNER ❑ <br />OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT <br />I(APPUc wr is not the P4n'C Purry proof of authodzotfon to sign Is ruquhvd Title <br />THORIZATION 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 environmental/Site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 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: <br />e <br />---r <br />COMMENTS: <br />PAYN9 LN'! <br />RE0tIs FI-.-' <br />JAN . ° 9 2002 <br />SAN JOAOUIP; •. _ .; <br />PUBLIC HEALTH SEPMCE <br />WARONMFNTa <br />INSPECTORS SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. <br />EMPLOYEE <br />DATE: _ <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount:Amount <br />`ice <br />Paid <br />Payment Date _ _a <br />Payment Type <br />Invo #' <br />Check # <br />S `� 33 <br />Received By: <br />