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as, andards, STATE and <br />0/ <br />that the work to be performed will be done in accordance with all Si JOAQUIN COUNTY Ordinance <br />DATE: APPUCANT SIGNATURE: <br />I also certify that I have prepa <br />FEDERAL laws. <br />. .plicatiof <br />SERVICE REQUEST <br />Type of Business or Property <br />41/\ <br />FACILITY ID # SERVICE REQUEST # <br />OWNER /%1ATOR <br />atec ( ) <br />BIWNG PARTY 0 <br />ok f) -keof S c,6) ' Yk.riC, <br />FACILITY .7-- i - <br />R3tr\ <br />NAME_Rie\ <br />1-: , Lool SC_ \fC.__ Sea-C, <br />SITE ADDRES5_, A - <br />' 70'h-ti-l-j- strvetHumber Direction OM --41°P1'6° Sf. M61"nf+CC6\ Striettfame Tyr,' Suites <br />Mailing Address_411 Different f rom Site=s) <br />crry ) _ <br />Latkro p STATE (2_ ZIP 715-)7D <br />PHONE 1/1 EXT. <br />()al) 82S. 3)00 <br />APN # LAND USE APPLICATION # . <br />PHONE #2 En <br />( ) <br />BOS DIsTREY I LOCATION CODE: <br />I <br /> <br />I <br /> <br />CTOR S / : • ST <br /> <br />REQUESTOR i %-- <br />3 <br />, , <br />ILLITY q) 4 (7 - BNG r AR / <br />EIY. <br />(V6 ) .3?-/601/4-) <br />BUSINESS NAME ji\kli kes_ri ()dm .r Fesit.) (r —PtierNrft---- <br />MAILING ADDRESS ,-1 k Lodi\ "i FAX # <br />(47/6 ) Fr- /67/ <br />CrrY <br />‘& lpr-Ar1 0 Wk STATE CA ZIP 4.1? 75762_ <br />BILLING ACKNOWLEDGEMENT: I. the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC HEALTH SERVICES ENVIRON AL &Int DMSION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />Cele/f/iTit4184 <br />PROPERTY/ BUSINESS 0 OPERATOR/ MANAGER OTHER AUTHORIZED AGENT 0 çtl V - <br />Appucmr is not the Crum PAnn' proof of authorization to sign Is required <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 environmental/site assessment information to the SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DivisioN as soon <br />as it Is available and at the same time it is provided to me or my representative. <br />TYPEOF SERVICE REQUESTED: iZ us L\ poi) <br />)) JO -.L rite CJ - <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />PPIM/A4 Nr "E-CeiVer). <br />gly <br />sAN JoAckE „ , , <br />OA/Wm* HHE SERVicrs ALTH olvisioN <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. d/7 EMPLOYEE II: 05 7 DATE: L5/7A ( <br />ASSIGNED TO: <br />\)S <br />I <br />IV% <br />EMPLOYEE #: 09 7 I DATE: 30-/g/0 l <br />Date Service Completed (i i/a - ady completed): SERVICE CODE: S-2 3 . PIE: 34,0 i <br />Fee Amount: 52 2 52._ Amount Paid 1 --- <br />_ -9-2 • 0 0 Payment Date <br />573/u / <br />Payment Type ,_„------ Invoice rt . Check # /0 ,:)- Received By: 6,6