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SERVICE REQUEST <br /> Type of Business or Property FACILITY IC# ' <br /> ll SERVICE REQUES'a, # t / <br /> ✓ / <br /> OWNER I OPERATOR BILLING PARTY I'. <br /> FACILITY NAME ') <br /> SITE ADDRESS 36-33 <br /> tr,-• r^r r ,r�/`r r°(' <br /> Street Nnmhrr tllrrtllon SL eel(deme _ Type <br /> Mailing Address (If Different from Site Address) <br /> CRY STATE�• ZIP � ` <br /> l� c r 5 <br /> PHONE#1 �T• APN# LAND USE APPLICATION# <br /> P}{ONE#Z EXT. �__ BOS DISTF C LOCATION CODE <br /> 17 OL <br /> CCl tTRAC C1 — <br /> } T R f5 ERVICE REQUEST R <br /> RFOUFSTOR f BILLING PARTY-F' <br /> BUSINESS NAME PHONE#-1,S- <br /> / ` !/ EAT. <br /> MAILING ADDRESS FAX# <br /> 1 I r> J t rJ u— vu 1) , S '' <br /> CITYr STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, tie undersigned property or business owner,operator or authorized agent of same. acknowledge Ihat all silo andlor project specific <br /> Pustic HEALTH SE;Ivicss EUVIRONMENTAL HEALTH DrviSION hourty Charges associaled with this project or activity will be bitted to me or my business as identified on this form. <br /> I also certify that I have prepared this appticatfon and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. } 1 r <br /> APPLICANT SIGNATURE, lel VC? fr {�ri7� i�:{ DATE: <br /> 7 1 <br /> PRCPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTPER AUTIIORIZED AGENT <br /> NArmr wr is not rhe QUelp _ <br /> Paar'i proof of aurhorinNan ro sign is nvQuired T if le <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located al the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaYsite assessment information to the SW JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRGNUFJUTAL HEALTH DIVISION as soon <br /> as it is available and at the same ilme it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 4r°O�?ji•�prF' 'if pili r J fC) <br /> �r t 1 p 7i� 5�� TN[�rT n. !�AYMENI <br /> kfirlr�JMNnT Sl; it l<91 5 !�!L'(4 Cl" c VNF• F�!'��Gr!'1 1 L c� -3 10 IS CC"j <br /> 07t S�'n v AUG 7 1998 <br /> or SAN JOAQUIN ruur•,f'r <br /> PUBLIC HEALTH SCRVICF1 <br /> 4 ! I ENVIROI`JMENTAr_IacAl_TH ISIOi <br /> �J lryUC,ryTi11V f�j'tJUr' DIV��?? <br /> Lonn?> ��"c�r►i licfl 17rar;a <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APP;cvu ay: EMPLOYEE 1: DATE: <br /> ASSIGNED to: Le ft" iI 5(' f' ' S EMPLOYEE 4: if)00 DATE: —/ <br /> Date Service Completed (if already completed): SERVICE CODE: P I ED 3 0 <br /> Fee Amount: Y Amount Paid 00Payment Dale <br /> Payment Type invoice I Chvk 4 Amy J— Received 8y: " "-' <br />