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SERVICE REQUEST 10 <br /> Type of Business or Property FACILITY ID# SERVICE REQU ST# <br /> DA l f-Y / <br /> OWNER/ OPERATOR <br /> UC V/ H �t C,"-Ab�AbtJy CHECK if BILLING ADDRESS <br /> V <br /> FACILITY NAME ` M, <br /> A(PLyf / <br /> SITE ADDRESS � Q.TR�C.LJn`� <br /> (oi4v� Street Number Direction L 1Street Na aType Suite <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> lo--30C L. FQGNI C_H CWI[P ROAD <br /> CITY INIAKT� STAGE �j ZIP <br /> �`-1 �33(�—8 7 1-7 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209) 982-1?2Z <br /> PHONE#2Exr. BOS DISTRICT LOCATION CODE <br /> 1 (209 °182- � 7 al <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORCHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# Ems' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACIiNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDER7:x <br /> ws <br /> APPLICANT'S SIGNATURE: Q. DATE: J(t4.- Z-(,p <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ;I PAYMENT <br /> COMMENTS: HF <br /> JUL 2 61�gg <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICE$ <br /> ENVIRONMENTAL.HEALTH DIVISIOr• <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED 6Y: EMPLOYEE#: DATE: �f <br /> ASSIGNED TO: I EMPLOYEE#: I DATE: I <br /> Date Service Completed (if already completed): SERVICE CcCE: �� i P E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type ! Receipt# Check# Received By. <br /> SRREOrev.doc 7/1/1999 <br />