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SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> 00 <br /> OWNER/OPERATOR /`T w-'6 BILLING PARTY <br /> FACILITY NAME MCI) <br /> 1L arL <br /> $READDRESS p"l r� fffr �7IJ ` i <br /> �v I� Sbwe Ninir 04�eCm ly r V ��1N111�M �YOe 4Wha <br /> Mailing Address (If Different from Site Address) <br /> 1� .. M-a t v ) <br /> CITY LA - STATE C A- LP 10 foo-3-l0(pto <br /> PHONE#t der. APN# LANDUSEAPPUCATIDN# QUj <br /> qv-)l a -8 q � - 010- p <br /> PHomi ' sy EaT. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING P <br /> BUSINESS NAME )L� PHONE# fir. <br /> (� <br /> MAILING ADDRESS FAX# <br /> !-W U S ?0(1) --1143— <br /> CITY <br /> 1!3—Cm lot `til STATE Zr <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business ovmer,operator or authorized agent of same. acknowledge that all site andfor prO*1 spedfic <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as Wefltfled on this font). <br /> I also candy that I have prepared this app"and that the weds to he perfomled wa be dam in accordance with ad SAN JCA"COuNrY ONinatce Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPucnHr SIGNATURE: ._� , �� oAre <br /> 9 <br /> PROPERTY/BUSINESS OWNER '19, OPERATOR/MANAGER a OTHER AUTHORRED AGENT <br /> llAPR,Gvrrkriarlfp 9uacPAerv.proaralwthMntlon roagn6nW:M 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 anJfor emYOnmentatsite assessment information to the SAN JoAouW COUNTY PUBLIC HEALTH SERYIGES ENVIRONMENTAL HEALTH Dw*N as soon <br /> as it is available and at the same time it's provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: utl _ F I <br /> COMMENTS: �J <br /> PAYMENT <br /> NOV 17 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOi, <br /> INSPECTOR'S SIGNATURE: �...t� CONTRACTooies SIGNATURE: <br /> APPROVED BY: EmpLay—at Coo X o DATE: J <br /> ASSIGNED TO: ` EMPLOYEE#., DATE: t <br /> Date Service Completed (H already completed): SERVICECGOE: 'P I Q �. <br /> Fee Amount ,�^C�� Amount Paid b Payment Date <br /> Payment Type Invoice# j C eck# By: <br />