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SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />SERVICE REQUEST # <br />oc� 3yb <br />S <br />pAc(lA(ru rIr �D,s7Rr&f� o� dZ <br />BUSINESS NAME <br />i <br />FAX # <br />BIWNG PARTY <br />OWNERI OPERATOR lM ^E^ �^ t % <br />STATE LP <br />Cm <br />FACILITY NAME _)1Oy L, yrs 9aA dJbQ S ECK -LS SuG/}R C! <br />�'^j/ <br />SITE ADDRESS �La``a <br />a�V <br />COMMENTS: <br />u _ <br />l 1 ya,M Xyin <br />DLa <br />�Q <br />"i <br />Tyle <br />Suite: <br />Street Numtrer <br />OirtC'on <br />Mailing Address (if Different from Site Address) Pb13� 60 <br />V <br />JvypPaom <br />STATE <br />CITY <br />I � <br />J <br />GA LP 9 ? 7B <br />W. APN# - LAND USE APPLICATION# <br />PHONE#i <br />Toch QS -32t0 Z7-� <br />ON <br />PHONE'XL EXT. BOS DISTRICT - <br />LOCATION CODE - <br />55-Lf9-1 <br />-N_ <br />rrr. •s�r.•alae.Toa�uea <br />BIWNG PARTY ❑ <br />REquESTOR <br />PHONE #' <br />BUSINESS NAME <br />i <br />FAX # <br />MAILING ADDRESS <br />STATE LP <br />Cm <br />BILLING ACKNOWLEDGEMENT: I, the undersigned Property or business ovmer, operator or authorized agent of same, acknowledge that all site and/or protect sc-a-i c <br />PUSUC HEALTH SERVICES ENVIRGNwENTAL HEALTH ONISiGN hourly charges associated with this Project or activity will be billed to me or my business as identified on this tans. <br />I also cerdly that I have prepared this application and that the work to be Perfa� will be done in acCurdance with cap SAN JOACUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. / .1-4 I <br />DATE: <br />APPLICANT <br />PROPERTY( BUSINESS OWNER ❑ OPERATOR MANAGER A OTHER AUTHORIZED AGENT U <br />❑APPLCc isni at,•S �P.wT'r. P�fofw0wriadon m sign is rKuuad Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I. the owner or operator of the property located at the above site address, hejrr11r1ea¢eby authorme the re!easa of <br />any and all results, geoteuhnial data andlOr environmentallslte assessment information to the SAN JOAQUIN COUNTY PUauC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISICN as eocn <br />e :t r n.w,:AoA M ma nr rM renRSerllatlVe. <br />as n Ll availdble auuaeUIC.,a., ...,,..._,._..___._...__ <br />. <br />TYPE OF SERVICE REQUESTED: <br />i <br />COMMENTS: <br />JvypPaom <br />CvWGE 1 <br />SP gUGNEP�SNEp�SNO <br />ON <br />NZW <br />EN`?z'dp <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE <br />DATE' <br />- APPROVED BY: <br />e ElIPLOYE=#: <br />ASSIGNED TO: 911�- <br />EMPLOYEE#: a - <br />DATE: <br />Date Service Completed (d already Completed): <br />SERACECQDE •- <br />P,'E: D <br />Fee AmountAmount <br />Paid a b� <br />Payment Date "j 1 b?) <br />Invoice# <br />Payment Type <br />Check# 3W0000 %'t+ Received 13y: _ <br />