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( )/ SERVICE REQUEST <br /> kji}w�►3usiness or Property I FACILITY ID# NMI SERVICE REQUEST# <br /> SArY `oCRnZU <br /> OWNERI OPERA+yD BILLING PARTY:_ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Str Nuftw D17rectl ' T 1 G\1 g V�,S. N. Type Surt.a <br /> Mailing Address (If Different from Site Address) <br /> I <br /> CITY STATE ZIP <br /> bp-t-h y o - °\ -S '33 0 � <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (z�i 9 - FsSgs <br /> PHONE#2 ET. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR 106 <br /> BILLING PARTYyy <br /> 06T, rVk =—(2\y\VA s © NN c ` <br /> BUSINESS NAM PHONE# Er <br /> -L) V\S a ti P-2 A c o\ Q LA VA. (sw4 97 &- 6 <br /> �MAILING ADDRESS FAX# <br /> P' 0' (_3 ox X116ck a bc,ct\ z3 q-7 6y39� <br /> j Crrr trT lit I, �� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project Specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH.DIVISION hourly Charges associated with this project or activity will be billed t0 me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL!AWS. p� <br /> APPLICANT SIGNATURE: i/GVV�r/` r DATE: �./—e4�— / <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT 0 COn"+ C-ee'-Q! _ <br /> IfAPPU„TismtUsBUMPAmY.Proof ofauthudaaBon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above she address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaltsite assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERvicEs ENVIRONMENTAL HEALTH OM$ION 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: <br /> PAYMENT <br /> RECEIVEC <br /> JUN 2 6 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APFROVED BY: Ex"=CYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#I Q` p DATE: <br /> Date Service Completed (if alr ady completed): SERVICE CGDE: 1 E: -Z_ <br /> Fee Amount: Amount Paid Payment Date b, , <br /> Payment Type Invoice# Check# Received By: <br />