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SERVICE REQUEST 1 J''0 �J <br />1/z - .sem V� S-� <br />Type of Business or Property <br />O rCG A� <br />FACILITY 10 # <br />SERVICE REQUEST # <br />OWNER P <br />BILLING P ❑ <br />FACILITY NAME <br />5 <br />SITE ADDRESS L/�rG1rrIC_Ave—r�lSbid Nn1w <br />DirectionITy" <br />�r Ir 1 4 fy� t <br />�t"'Y:tl fiw9�P�C�Y <br />Sui411 <br />Mailing Address (If Different from Site Address) <br />_ <br />CITY <br />STATE ZIP <br />PHONE #1 Exr• <br />141 478 - S. () 4 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ar• <br />BOS DISTRICT <br />LOcaTtoN CODE <br />CONTRACTOR! SERVICE REQUESTOR <br />REQUESTOR BILLING PARTY ❑ <br />O rCG A� <br />BUSINESS NAME <br />seCL ^� c .VQql <br />PHONE# Fxr. <br />gig q <br />N G ADDRES�Ss,, <br />7.D �kso S b 8 <br />FAX # <br />CITY \ ST TE ZIP <br />BILLING ACKNOWLE a undersigned property or business owner, operator or authorized agent of same, acknowledge that al site andlor project specific <br />PuBLic HEALTH SERVICES E RONMENTAL EAL *N hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />1 also certify that I hav re a the�iw A o be performed Will be done in accordance with ail SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: / r=rte DATE:' (�/i`�,I <br />PROPERTY! BUSINESS OWNER ❑ <br />OPERATOR /MANAGER Cl OTHER AIrIFIORRED AGENT L v�+4 *6e/L <br />NAPPLI iwr is not the ftLM urrr proof of authorizadon to sign is required rifle <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 anlllor environrnentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERw.Es ENVIRONMENTAL HEALTH DiVt m as soon <br />as it is available and at the same time ii is provided to me or my representative. <br />I <br />TYPE OF SERvbcE REQUESTED: " <br />�^ <br />C <br />�.' <br />�J <br />COMMENTS: <br />�r Ir 1 4 fy� t <br />�t"'Y:tl fiw9�P�C�Y <br />APR 61999 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICE:, <br />ENVIRONMENTAL HE 1TH DIVISK <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: �, <br />EmPLwY°-#: �(� l <br />DATE: <br />ASSIGNED TO: G <br />EMPLOYEE #: ( <br />DATE: <br />Date Service Completed (if already completed): <br />SERVIMCODE: C; <br />'P IE:. � '= <br />Fee Amount:5?_ <br />Amount Paid <br />Payment Date <br />Payment type <br />Invoice # <br />Check # �(S <br />Received By: ' <br />1 40 <br />