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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUES <br /> C,Lij-i <br /> OWNER OPERATOR BIWNG PARTY❑ <br /> FACILITY NAME <br /> TS G1 ✓ / e— <br /> sTTE BB F �cz�`er�ao 9CSMlbas TYP. svwa <br /> SIMNurta ov.rme <br /> Mailing Address f Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 exr• APN# LANDUSEAPPLICATpN# <br /> PHONE#2 err. BOB DISTRICT - LOCATION CODE. <br /> • CONTRACTOR I SERVICE REQUESTOR <br /> REDuEsTOR Sum PARi�'. <br /> _(Od` <br /> BUSINESS NAME �\ # (i EU <br /> ^2rsdYl ��L C O <br /> MAILING ADDRE L FAX# _j � <br /> Q Cl d 1 <br /> CITY STATE ZP f a <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owrw,operator or authorized agent of same,aduwwledge to all site andlor pmjed specific <br /> PUBLIC HEALTH SERVICES ENVIRONLENTAL HEALTH DIVISION howdy charges associated with This project or activity wi0 be billed to me or my business as identified on this form. <br /> 1 also cerdfy that I have prepared this application and,that the work to be performed will be done in accordance wilh all SAN JOAOUW COUNTY Ord"=Codes,Standards.STATE and <br /> FEDERAL haws. )) p <br /> DATE' <br /> APPLICSIGNATURE: ��- <br /> ANT <br /> PROPERTY/BUSINESS OWNER ❑ OPEAATORIIAANAGER ❑ OTHER AurHORDED AGENTOIT '`e CL <br /> aAMuC,wrisratdre891MPAM.Pres/OfXMICrIudar to semis required Tine <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby author®the release of <br /> any and all results,geotechnical data asllor eavironmenmpsae assessment infornadon to the SAN JOADLIN COUNTY Pueuc HEALTH SERVICES ENvwoNuEmTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it's provided to me or my representative. <br /> TYPE OF SERVICE REDUESTED: h <br /> COMMENTS: CE,9Vpn <br /> DEC 41. 01998 <br /> 0 a rSIN'• PUBLIC OF�AQUIN COUNTY <br /> ENVIRONMENT AALTH SERVICES <br /> 4 .,-.1 AL HEALTH DIVISION <br /> INSPECTOR'S SIG RE: CONTRACTOR'S SIGNATURE:`^"' <br /> APPROVED EMPLCYEE1f: Ir'' DATE: /� VL0 1 <br /> ASSIGNED TO: �. �. ,n 4' EMPLOYEE#: LJ00 DATE: z. �b <br /> Date Service Completed (if al completed): l SeRVIra CODE j P f F—= <br /> 5 00 <br /> Fee Amount Amount Paid `j //S9 ,C7O Payment Date <br /> Payment Type <br /> Invoice III Check# �j�/ Received By: <br />