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` • SERVICE REQUEST • <br /> Type of Busines r Property FACILITY ID# SERVICE REQUEST#�(T <br /> OWNER/OPERATO r r[J BALLING PARTY❑ <br /> TAkm <br /> /1 LLJ <br /> FACILITY NAME r <br /> SnEADDRESS ,I�/� / O <br /> Numbr(_9ueel <br /> /T"Street er irecfian Type SukeR <br /> Mailing Address (If Different from Site Address) <br /> Cm STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1209) 139 - 792- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> n CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTO / BILLING PARTY, <br /> BUSINESS NAME 1J/✓'—f-/f( �� PHONE#52A ��/ �33 7 ETr. <br /> MAILING ADDRESS �IS---fl'/U--' I. FAX# / <br /> lJ �(J o �/- (0 34,12 <br /> CM /rte 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 to me or my business as identified on this tone. <br /> I also cemly 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 laws. q ry <br /> APPLICANT SIGNATURE: DATE: I s (�eO / 6 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORim AGENT <br /> IfAPPuuwrisfatre8rwNCPnrrrv.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,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 environmentallshe assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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: wV11A CrL, <br /> COMMENTS: n\PAYMEE�E N:.. <br /> RFS(`f:"90/rF <br /> OCT 2 7 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBIC HEALTH SERVICIES <br /> ENVIRONMENTAL HEALTH OIV SIt':_e <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: f � EMPLOYEE#: /bp't» DATE: .�'\ a7/I? <br /> D <br /> ASSIGNED TO: VT _ �I � EMPLOYEE#: VA7� C <br /> � DATE: � U <br /> Date Service Completed (if already completed): SERVICE CODE: P I <br /> Fee Amoun : ) bz) Amount Paid054Payment Date _ <br /> Payment Typ Invoice# Check# 2h II 0CD <br /> Received By: <br />