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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST» /l <br /> i OWNER/OPERATOR BU1rNG PARTY❑ <br /> FACIUIY WE r_ <br /> SITE AooRESS <br /> 175 1 '-�n k` H � <br /> Mailin Address (If Different from Site Address) <br /> 2 i N C- f�r♦ n�n L L act( 5� Y <br /> CITY STATE ZIP <br /> PHONE#1 N# IAUCA <br /> NO USE 9 <br /> PHONE#2 aT• 603 DtsrwcT LocAnoN CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQuESTOR BU JNG PARTY❑ <br /> BUSINESS NAME PHONE# cu. <br /> hWUNG ADOREs3 FAz# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorizad agent of same, adviowiedge that as 3Ae and/or project specific <br /> Puauc HEALTH SERvIcEs EwiRcta4aaAL HEALTH DNr"hourPj duuges associated wi h Chis project or activity will W bGcd to me o f my business as idemtified on this formt <br /> I aL3o cor»ty that I have pro this apprx ion and that the work to be pertomied WA be done in acc uJanca with allSArI JOAaT COUNTY Orrfinenoe Codes.Standards,STATE and <br /> aws <br /> FEDERAL l . <br /> r <br /> "A4PPLICA1rT Sic"TU DATE 0 6 <br /> PROPERTY/BUSINESS OWNER 01� OFERATW ❑ t THMAUTHoRR AGENT ❑ <br /> \ YAvPrr.Amra rxc a,.BLL#c yr0or0rw0"t3don tusiVa Jj rr7jrvd TIu. <br /> AUTHORIZATION TO RELEASE INFORMATION:When appbcabie.L this owner or operator of Ma property located at the above site address,hereby 3Udxxtae the rebase of <br /> any and all re`.utts,geotechnical data ark1kc err4wunenta!ls4e assossamt intomnatlon to the SAN JOAam COUNTY PUULK HEALTH SERvICES Ercv>Ftorwaax-HEALTH Om=N as soon <br /> as K is amiable and at the same tlme i k.provided b mo or my rnepreseatattva <br /> TYPE OF SERYKE REQUESTED: V� <br /> STCV-\ <br /> COMMENTS: CnTEa�lro�vofT#E &AIeRe74 We44 6&c, - <br /> To / �auE TSF <br /> 7H6 15071f H6S3--<1v p r pr,�7��. T Q�wrlec�rE if.�s Bc�iv c'o,v e7�D THF <br /> CoN�REre� IoW, TFf�S �Rovrtiov o� TNF 4i9kb USE CavbiTiotis PAYMENT <br /> ,fpsti r�s�— DECEIVED <br /> ,` 10 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIO', <br /> INSPECTOR'S SiGRATURE_ CONTRA=FeS SIGNATURE: <br /> APPROvEO aY: EYPLDy` 31: 7 DATE: <br /> AssIGHEDTO: EYPLoYEE#— f I_ qq DATE: <br /> Date Service Completed (rf alrea completed): �P I SErtv>cE CODE P l E; <br /> Fee Amount: 0(s)' Amount Paid DO Payment Date <br /> Payment Type Invoice 9 Check# & & (o Received By: / <br />