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SERVICE REQUEST <br /> EH0061 SR revised 09/04/98 <br /> Type oBusneFACILITY <br /> ID# SERVICE REQUES T# I <br /> -41 <br /> ilei c >3 <br /> OWNER I OPERATOR <br /> C BILLING PARTY <br /> FACILITY NAME (^ <br /> AIW V <br /> SrTEADDRESS0�5 <br /> Strut ii dnxtion ma'x) Sb Mane 77F'. suits <br /> Mailing Address (If Different from Site Address) <br /> Cm STATE LP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 7 <br /> PHONE#2 0* BOS DISTRIcr LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> S Id k v BILLING PARTY❑ <br /> BUSINESS NAME PHONE# EAT. <br /> 2— <br /> MAILING <br /> MAILING ADDRESS FAX# <br /> CITY �IDCC'c STATE LP CS_ (, <br /> BILLING ACKNOWLE GEMENT: I, the undersigned property or business owner, operator or authorized agent of same,.acknowledge that all site- <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this forth. <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 <br /> Ordinance Codes, Standards,STATE and FED laws. <br /> APPLICANT SIGNATURE: ��-�- .'/' DATE: �'/ �f <br /> ESS ER "98 <br /> PROPERTY/BUSIN ❑ OPERATOR/MANAGER ❑ OTHERAUDIORIMAGENT ❑ ' <br /> I/APPLIcwts not the BILLING PARK proof ofardhor®ffon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results,geotechnical data andtor environmentalisite assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: _ <br /> COMMENTS ❑ SPECIAL COWDON(S)OF APPROVALOTHER ❑ <br /> PAYMLN <br /> RECEIVED <br /> SEP 141998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> I <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: EMPLOYEE#: _ �p t DATE: Cj (• <br /> ASSIGNEOTO: ron EMPLOYE--#: R'i41� DATE: ! qQ <br /> Date Service ComYpleted (if already completed): S`---ERVICWWE CGDE: i") p)E; CO) <br /> Fee Amount- ', Amount Paid Payment Date I <br /> I <br /> Payment Type Invoice# Check# Roceivod By: <br />