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SERVICE REQUEST <br />Type of Business or Property <br />FACILITY IIID,,# <br />1 <br />SE`RRVICCE/R'}E�Q)UEST» <br />BUSINESS NAH C <br />9 <br />�IT <br />73 <br />-� ADDRESS ��C <br />.j <br />F�r-e-- q <br />CrTY J ids_ <br />S1ATE ZIP <br />SAN JOAQUIN COUNTY <br />CIWNERtff_ <br />_ <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENA[ HEALTH MVISICPi <br />BUMG PARTY <br />CONTRACMes <br />SIGNATURE: <br />APPROVED fil(: <br />FACS NAHE._ <br />UBATE: <br />2j, 76 d <br />ASSIGHEDTO:S <br />Emp oYEE#: 3 <br />SITEADORESS <br />02 l <br />Z � <br />�,i.t <br />r �—� <br />Q�„�t <br />r�T <br />-PIE- <br />0 off— <br />s� Numbw <br />Dvocno� <br />�,. ��. <br />Payment Type <br />Invoice <br />Mailing Address (If Different from Site Addressl <br />J; ;j -7 <br />Received By: <br />-7.C--�' Z akE" <br />CITY \ <br />STATE ZtP <br />C?\,Sv2 C7 <br />PHONE #1 Err. <br />( <br />APN # <br />LAND USEAPPUGAT)oN # <br />PHONE #2 Err. <br />BOS DISTRICT�CO <br />CONTRACTOR f SERVICE REQUESTOR <br />REQUESTOR <br />1 <br />BUSINESS NAH C <br />9 <br />PAYMENT <br />PHONE# [u. <br />-� ADDRESS ��C <br />.j <br />F�r-e-- q <br />CrTY J ids_ <br />S1ATE ZIP <br />SAN JOAQUIN COUNTY <br />_ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or businass owner, operator or authorized agent of sans, admowlodgo That all site andlor project specific <br />PUBUC HEALTH SERvrEs ENmoti .rE a& HEALTH omstoN hourly diarges associated with this project or advdy will be Wed to me or my business as idend8ed on this form <br />I also comfy that I have prepared this appfica ' and that the work to be performed wl be dant in aaorda= with az SAN JOAOUIN COUNTY Ordinenoe Codes, Sfanderds, STATE and <br />FEDERAL lam. 7 /y <br />APPLICANT SIGNATU DATE / �L 7'!/ <br />2- <br />PROPERTYI BUSWE,SS OWNER 0 T MANAGt3i (t3' OTNFAAUn10RJZEDAG✓ f(T 0 <br />Y thea/1,lvSi,pvaof"Mor"UmtoSim isrequind Titre <br />AUTHORIZATION TO RELEASE INFO RMATIQN: When applicable, L the owner or operator of Cw proparty located at the above site address. hereby audxxtzs the rebase of <br />any and ail results, geotechnical data amilor w4onmentaVsb asumvnent irtfomrarion to the SAN JoAam WiNTY Pwx HEALTH SERvLcEs EtJYpwmENrAL HEALTH ONTS" as soon <br />as it is available and at the same Wne it is provided b me or my represmtatIve. <br />TYPE OF SERvICE REQUESTED.- <br />EQUESTED:COMMENTS: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />CLEC 3 020-U4 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENA[ HEALTH MVISICPi <br />INSPECTOR'S SIGNATURE: <br />CONTRACMes <br />SIGNATURE: <br />APPROVED fil(: <br />Ems: 1t: ?0 <br />UBATE: <br />2j, 76 d <br />ASSIGHEDTO:S <br />Emp oYEE#: 3 <br />Date Service Completed Crf already completed): <br />SERvIC:CooE: <br />-PIE- <br />0 off— <br />Fee Amount: <br />Amount Paid <br />�� _ <br />Payment pate l y(3 I /� � <br />Payment Type <br />Invoice <br />Check # <br />J; ;j -7 <br />Received By: <br />411 <br />K <br />