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�.. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE Rj(,�EST# i <br /> OWNER OPERATOR !, BIIJJNG PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS N ���� <br /> 20's- su..x orr.a� �;e�,�e1 C}� YP. saes <br /> Mailing Address (If Different from Site Address) <br /> CITY �An-_ (9��STATE LP <br /> PHONE#'I W. APN# LANDUSEAPPLICATXIN# <br /> PHONEY Ea. DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR BUM PARTY <br /> U <br /> BUSINESS NAME PHONE# W, <br /> 3- SOSx <br /> MAILING ADDRESS FAX# �v 5 <br /> �. _ <br /> CITY STATE L'�� ZIP t)5-it 0 S- <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that ad site andlor project spedfic <br /> PUBLIc HEALTH SERVICES ENVIRONMENTAL HEALTH ONLSION hourly changes associated with this project or activity will be billed to me or my business as identiled on this farts. <br /> I also Pertly that I have prelocation and that the work to be perfomhed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Cddes,Standards,STATE and <br /> FEDERAL laws. 2J <br /> APPLICANT SIGNATURE: \ - DATE: ` Z/ !Z 7/ <br /> PROPERTY/BUSINESS ONNER 0 OPERATOR/MANAGER ❑ OTHER AIRHORRED AGENT ❑ <br /> rcArA(.wrmmral etic�.cGPa vProoralwmwndon rosgnii nw&.d <br /> rue <br /> AUTHORIZATION TO AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authors the release of <br /> any and all results,geotechnical data antifor emironmer uditsite assessment infamation to the SAN JOAQuN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION as soon <br /> as k is available and at the same time it s provided to me or my represe'nt�ativvee..�y�J <br /> TYPE OF SERVICE REQUESTED: �V\'i <br /> COMMENTS: <br /> PAYMEN7 <br /> Rps`stven <br /> MAR 15 1999 <br /> SAN JOAOur <br /> ENVIRONMENT3E ly <br /> q LHEACT.PC <br /> p V SIOn <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: �— EsulwmA: `�Dv ] DATE: 3 I <br /> ASSIGNED TO: S(�-� EMPLOYEE#: b DATE l <br /> Date Service Completed (Nalready completed): SERVICE CODE p3 'PIE- 3� <br /> Fee Amount: - �3 Amount Paid �3y.. PaymeMK Date 3 151 R G <br /> Payment Type ,j Inv ice# Check <br />