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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> , SCO -�- 06� 34C-a� Std fc FA G 0 U <br /> a OWNER/OPERATOR BILLING PARTY 0 <br /> FACILITY NAME <br /> _(,0 <br /> SITE ADDRESS �� t <br /> �_ - � sWW NUftW OiArIL, Strut Num <br /> TYPe Suite Ir <br /> Mailing Address (If Different from Site Address) <br /> CITY Tr ^h C .,` STATE CA <br /> ZIP "N-5-767 <br /> . <br /> PHONE#'1 f - TPN# LAND.USE APPLICATION# <br /> PHONE#2 a►• BOS DISTRICT LOCATION COOE., <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> �1 ( C—,y S Tic 0 <br /> BUSINESS NAME PHONE# Exr <br /> MAIUNG ADDRESS F <br /> CRY 9M- ( {-(C-) SOP, STATE ZIP <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that ab site and/or project specific <br /> PUBL{C HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated With this proiect or activity Will be blued to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the Work to be performed will be done in accordance With all SAN JOAQuw COUNTY Ordinance Codes,Slandards,STATE and <br /> FEDERAL laws. r r <br /> APPLICANT SIGNATURE: ( Al DATE' r If 6 ✓}0,�— q, <br /> PROPERTY/BUSINESS OWNER OPERATOR/MAU.R 0 OTHER AUTHORmAGENT <br /> YAPPLIGWr is not fhe Br.m Pam:proof of sudiatudon to sign is requavd 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 environmentaltsite 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 /> vs VICI- <br /> COMMENTS: Q <br /> f 3 �.� <br /> • R �,924®2 <br /> C <br /> �p,N t\C NEAII�EP�SN DN\�\. <br /> INSPECTOR'S SIGNATOR . CONTRACTOR'S SIGNATURE: �\R <br /> APPROVED BY: EupLOYEEt: DATE: 17 (Y 2 <br /> lY Gi <br /> ASSIGNED TO: - EMPLOYEE#: DATE: <br /> :.Date Service Completed (if already comSERVICE CODE: f` -P <br /> Fee Amount Amount Paid 4� L1 �-� Payment Date. <br /> Payment Type Invoice If l Check# 139()3 *a(oReceived By: �� <br />