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SERVICE REQUEST EHOO61SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#� <br /> OWNED;ERA[OR LA>` BILLING PARTY <br /> FACILITY NAME <br /> %.v 1 1'ACi SF.1Z-�1 lL�,, Gam► <br /> SITEADDRESS <br /> L-AA�,' cL,/ <br /> 7� u be Direction T Street Name <br /> Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> v c) <br /> CITYL,-6`\ STAT^ ^ GIP <br /> PHONE#1 L EXT. APN# LAND UvSE'ASPPLICATION# l <br /> 33— 0 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> 333- o <br /> CONTRACTOR/SERVICE REQUIESTOR <br /> REQUESTOR ;fA <br /> BILLING PARTY❑ <br /> BUSINESS NAME PHONE# EXT. <br /> L-\ a - 3 3 <br /> MAILING ADDRESS FAX# <br /> 25 W1 W it � — 3�kZ <br /> CITY <5Tbi✓ STA ZIP �ZD--) <br /> BILLING ACKNOWLEDGEMENT: 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 /> 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, TE and F RAL s. <br /> APPLICANT SIGNATURE: DATE: �- (� y°O <br /> z <br /> PROPERTY/BUSINESS OWNER OPE TOR/MANAGER )iT-- OTHER AUTHORIZED AG NT ❑ <br /> If APPLICANT is not the BILLING PARTY 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 site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site 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 CONDITION(S)OF APPROVAL❑ OTHER ' ! ! :" ❑ <br /> DEC 11 1998 <br /> SAN JOAQUIN COUNTY <br /> PU <br /> t:NVIRONMENTAL HEALTH OIV!SION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: � EMPLOYEE#: DAT :zv'T�' <br /> r` <br /> ASSIGNED TO: E7AfG— v <br /> EMPLOYEE#: �Vi DATE: 2/er <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: �3 �- Amount Paid 231—/ Payment Date <br /> Payment Type Invoice# Check# c?c/ Zf Received By: '�-- <br />