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SERVICE REQUEST <br />Type ut Business or Property FACILITY ID # <br />SERVICE <br />OWNER OPERATOR <br />Y rTv L/y(/jyV 75Z<DQ� C� 20C <br />FACILRY NAME <br />rC9-�t7Z�3 u s „J Ess PSL <br />SITE ADDRESSK-2727 <br />54 <br />sv ax. br ��e' i <br />Mailing Address (If Different from Site Address) <br />RM <br />PARTY ❑ <br />Crtr I r—1 Cil STATE n^ LP G <br />PHONE #1 �C CIS 3 7 <br />�T• e29 8(p (o APN # LAND USE APPLICATION # <br />- 80�p <br />PHONE fie Ear• BOS DISTRIL7 <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />S E M `-'t-7 BILLING PARTY9 <br />BUSINESS LANAE <br />SEM PHONE# ` U �+ / Err. <br />MAILING ADDRESS -+ z �L ! („ps 3 <br />� <br />�+tZ S �" 1 S �— FAX# <br />CITY] A STATE Al S 2 Y— O Sd 3 <br />C+ Zip 5535/ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property of business owner, operator or authorized agent of same, acknowledge that all site and/or project spedrk <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity win be billed to me or my business as identirred on this fomL <br />I also certify that I have prepared this a 'on and that the work performed will be done in aaardance with an SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: <br />DATE: p �-�• � , I <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHERAUTMUI, AGENT I!ZCt AA rL, <br />I/AaaUc.wrisr,d tle sign Braquhad 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 and/or envimnmentaVsite assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNmioN 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: 06T �! n <br />COMMENTS: <br />�JAYLMEN t <br />WA15 <br />• <br />SAN JOAQUlpq <br />FUBIJC HEALTH difIR CES <br />t/ <br />ENVIRONMENTAL HEALTH ONW,, <br />INSPECTOR'S SIGN ANRE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:, <br />EMPLOYEE#: --2 <br />ASSIGNED TO: 9G <br />EMPLOYEE#: - DUI <br />DATE: , j V <br />Date Service Completed (if already completed): <br />SERVICE Co DE: 3 P I E' <br />Fee Amount: <br />Amount Amount Paid <br />payment Date <br />Payment Type <br />Invoice #' <br />Check # <br />Received By: <br />