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r <br /> SERVICE REQUEST <br /> Type of fusiness or Property FACILITY ID# SERVICE REQUEST# <br /> r� ®344 sk 3 �� $� <br /> BILLING PARTY❑ <br /> OWNER I OPERATOR <br /> L� —a' <br /> FACILITY NAME <br /> SITEADDRESS 1 ci EY P�Number <br /> Direction Street Name Tyype" <br /> Suitt 2 <br /> strw Numb <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZI��� . <br /> 5-1�)r\ <br /> PHONE#'I a*• ____JAPN# LAND USE APPLICATION# <br /> PHONE#'I SOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REDUESTOR BILLING PARTY <br /> BUSINESSNAME PHONE# Exr. <br /> ST ° S '�jjf -7 <br /> MAILING ADDRESS FAX#told ^� <br /> !/I <br /> COY STATE Z1P <br /> BILLING ACKNOWLEDGEMENT:t,the undersigned property or business owner,operator or authorized agent of same.acknowledge that all site and/or project specific <br /> Pusuc HEALTH SERvtCEs ENvtRONmENTAL HEALTH DMsION hourly charges associated with this project or activity will be billed to me or my business as identlFed 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 JOAOM COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> - APPLICANT SIGNATURE:�� n / y DATE. ��O/U 3 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHOR¢EDAGENT �— <br /> NAPRacwrisnot the 61te+cPAary.PMdOfaufhor"d0ntoSig"isrWbvd Ti 1e <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 au results.geotechnicat data andlor environmentallsite assessment information to the SAN JOAOUW COUNTY PUBLIC HEALTH SERVICEs ENviRONMENTAL HEALTH OMSION 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 /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JUN,3 0 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC SERICES <br /> ENVIRONMFNTAILTH FAI TH 0Il SION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: Evnam#: -1 DATE: 36 03 <br /> ASSIGNED= EMPLOYEE# a DATE P& d_ <br /> Date Service Completed (N already co Ieted): SERVEE CODE: ��• P/E: <br /> Fee Amount: 7,00 Amount Paid Payment Date 8 <br /> Payment Type Invoice# Check# Received By: <br /> Pr <br />