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%W SERVICE REQUEST ..� <br /> Type of Business or Prop" FACILITY ID# SERVICE REQUEST# <br /> C 0031 <br /> BILLING P <br /> OWNER I OPERATOR <br /> 'N' m 1A) <br /> FAc trY NarE <br /> SITAEE <br /> 1 P� <br /> se..eRws.. ouwen C- I( se.0 Tv,.. swe.e <br /> Mailing Address (If Different from Site Address) <br /> CnY STATE ZIP <br /> PHONE#1 FST APN# LAND USE APPLICATION# <br /> ('.,50 [v,G b b <br /> PHONE#2 BOH DISTRICT LOCATION CODE. <br /> z� c - 237 r <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR � BILLING PARTY 0 <br /> Am LID (;?oPA C C oc- <br /> BUSINESSNAMEPlbl�H � <br /> CC GPp £ 'ro 2 20\0 <br /> MAILING ADDRESS ` L FAX# U <br /> CITY STATE C A zP /5Zq <br /> o n `OT <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge @let all site and/or Project specific <br /> Pueuc HEALTH SFAVICES ENVIRONMENTAL HEALTH ONrION bounty charges associated with ms project or activity,will be billed w me or my business as identified on this form. <br /> I also tardy that I have prepared this application and that the work to be performed vAll be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes,Standards.STATE and <br /> FEDERAL IaW$. n r/, <br /> APPLICANT SIGNATURE: /4Ylh- l �t-. `�L-p.^"�^�- DATE: W.�O <br /> PROPERTY I BUSINESS OWNER C UORI MANAGER C OTERAUTHOR®AC$R 1 �p '� <br /> Il APPJ.wf S Nat NeBw,c P,wrn.geefvl wMWntlan bion b Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,],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 an ifor environmentaltsite assessment information to the SAN JoAQUIN COUNTY PUBLIC HEALTH SERVICES EwRONIBfTAL HEALTH DIVISION as Soon <br /> as it is available and at the same time it is Provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �^ <br /> COMMENTS: nnPAryryYME f <br /> DEC 9 1998 <br /> SAN JOAQUIN COUNTY <br /> ENVIP NMENTALTH SERxnrF <br /> AL HEALTH DIVSICIn <br /> INSPECTOR'S SIGNATURE: CONTRAcTofes SIGNATURE: <br /> APPROVED HY: EePLOY—at DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (ff already completed): SERVICECODE: I�4. <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type Invoice# Check# eeeiwed�' <br />