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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST„" <br /> OWNER/OPERATOR <br /> BILLING PARTY <br /> FACILITY NAME CJ. <br /> C w`-- yv— Liev-q 1c-e/vA s <br /> SITE ADDRESS 7 \J,�II <br /> I strret NumDu 0 .".) �" Stmn Nims <br /> Mailing Address (If Different from Site Address) <br /> CITY <br /> STATE ZIP <br /> PHONE#t APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT <br /> LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQIIFSTOR <br /> j BILLING PARTY❑ <br /> BUSINESS NAME �^ <br /> r'Y/ O r2 rz — c _ ,G-,ly )GLS _... __ PHONE# AZT. <br /> MAILING ADDRESS <br /> /// c c�rF/tJ 7' /� FAx# <br /> CITY <br /> ,�O�Q.% STATE �� 21P C <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned roe zr <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly chargesbasswated owner, <br /> this protect Ofactivityauthotwill beed abilled to Me of my business gent of same, las dentiedge that lfied on this(Ofsite and/or piT. specific <br /> I also certify that I have prepared this plication and that the work to be performed will be done in accordance with all SAN JoAQUIN COUNTY Ordinance Codes, Standards, STATE and <br /> FEDERAL laws. <br /> PUCANT SIGNATURE: << O- <br /> DATE: 7 <br /> PROPERTY/BUSINESS OWNER , OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> n APPtr wr is raf(he @jLLM PAg pmol or authonxidoq to sign Is rv"kvd 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 environmentallsite assessment into rnation to the SAN JOAQUIN COUNTY PUBLIC HEALTH S <br /> as it is available and at die saine tune it is provided to me or my representative. ERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> +^+ R"N <br /> nacc <br /> Li <br /> JUN 2 81999 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE M <br /> DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE#: ��� DATE: C ) 7 r <br /> Date Service Completed (If already Completed): <br /> SERYICE CODE: p�E: <br /> Fee Amount: <br /> Amount Paid � —' payment Date <br /> Payment Type Invoice# t� <br /> Check# '� Received By: j <br />