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., SERVICE REQUEST v <br /> .Type of Business or Property FACILffY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR - BILLING PARTY❑ <br /> PX1,14 <br /> FACILITY NAME Lo Pr+ / ' `6. <br /> SITE ADDRESS�C r �L ( ( liL <br /> � Sbwr N�mEY gnNon Spw[Nam. <br /> Mailing Address (If Different from Site Address) <br /> CITY 'T& <br /> STATE-, ZIP <br /> PHONE Al Ocr. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 pT BOS DISTRICT LOCATION CooE. <br /> CONTRACTOR/SERVICE REQUESTOR <br /> 1--c <br /> STOR • BILLING PARTY❑ <br /> U /� l <br /> CTp <br /> INESS NAME ,,//�� PHONE# Csc <br /> PO Tri a s /f,5 T/4✓k 7 5�uNGADO s FAX# <br /> S7��ILING ACKNOWLEDGEMENT: 1, the undersigned property or busineu awner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBTIC HEALTH SERVICES ENVIRONMENTAL HEALTH Ova"hourly charges associated with this projector activity will be billed to me or my business as identified w this tom <br /> I also certify Nat I have prepared this application and ttat the work to be performed wiz be done in accordance with all SAN JOAQUW COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> Pl1CAeli SIGNATUl1E: W �L�iZ� DATE• y/-�j <br /> J <br /> tiP CATV I SUSNESS O 6WRATORI MANAGER ❑ OTHERALTHORREO AGENT ❑ <br /> MAvaF arofffn Su P,vrrr.pod of aatlr oaw bsVna Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the awner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all n uts,geotechnical data and/or emvonmentallsite assessment informadon to the SAN JOAQUN CouNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH ONiSION as soon <br /> as it is available and at the same time it is pmvided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: rL '(1 <br /> D� e� 0 p <br /> INSPECTOR'S SIGNATURE: • CONTRAcTOR's SIGNATURE: <br /> ' APPROVED BY: �\ EmpLOYEr ff: cz, )1 DATE: <br /> AsSiGNFDTO: I I i EMPLOYEE#: ��-� DATE: <br /> Date Service mp(eted lellrea completed): SERVICE CODE: '. 'PIE- <br /> :Ie! <br /> I Ec ( bo <br /> Fee Amou "6 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />