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• SERVICE REQUEST EH0061SR revised 09/04/98 <br /> FACILITY ID# SERVICE 13&,Q ST J f <br /> Type of B sin s or roperty // rctJ <br /> L <br /> BILLING PARTY <br /> OWNER OPERATOR O Y�(1 <br /> 4 0 <br /> FACILITY NAME <br /> SITE ADDRESS LIQ q' Dire tion G '6U Str.ee Neme rya. Suites <br /> StrM <br /> Number <br /> Mailing Address (If Different from Site Address) <br /> CITYSTATE LP cJJc Z J s <br /> S —o <br /> PHONE#1 p }y E+T APN# LAND USE APPLICATION <br /> E ` o O r BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> kL� <br /> PHONE# � Err. <br /> BustNESs NAME JTo.�L� '� <br /> �o ti s <br /> FAx <br /> MAwxG ADDRESS O 20 oa �t1 2y. ��Z" Imo'✓p� <br /> C/ STATE ZIP I�JI'.3 LJ <br /> CITY a C <br /> BILLING ACKNOW DGEMENT: 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 form. <br /> work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> 1 also certify that I have prepared this application and that the <br /> Ordinance Codes, Standards,STATE and FEDERAL I _ / <br /> DATE <br /> APPLICANT SIGNATURE <br /> PROPFilrYI BUSINESS ER ❑ OPERATOR/MANAGER ElOm1ERAUn10NffOAGENT <br /> IfAPPuuNrisnot lire ttlulNc PARry Proof ofaudror®Oon m alp is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, 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 and/or environmentaYsile assessment information to the SAN JoaoulN COUNTY <br /> PueuC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as R is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> A/ v <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> a.°FCi 01 i,. <br /> S�� t 4 1998 <br /> sAN�aat,um -o��au; <br /> PUBLIC.- -..g <br /> ENVIRONMENIA, -,- <br /> sP OR'S SIGNATURE: <br /> CONTRACTORS SIGNATURE: DATE: <br /> EMPLOYEE#- DATE: <br /> APPRovEO ar: r � � <br /> ,p EMPLOYEE : C> <br /> # bo� DATE' 1 <br /> ASSIGNEDTO: �)/<1 6a <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: fJ � 1 2�� <br /> Fee Amount a� Amount Paid r Payment Date <br /> Payment Type <br /> Invoice# Check# Received By: <br />