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SERVICE REQUEST <br /> [FActuTy <br /> of Business or Property FACILITY ID# SERVICE REQUEST# <br /> tfA/( <br /> RI OPERATOR <br /> (710^/ (/tvVrA C' BILLING PAR <br /> NAME <br /> _/qC /0N V��� <br /> SITE ADDRESS <br /> S6 S0 <br /> strnnt Nump�t WeNon SUM NmI� Type Sully/ <br /> Mailing Address (If Different from Site Address) <br /> CRY STATE Zip <br /> PHONE#� Ear. APN# LAND USE APPLICATION# <br /> (z07) g yv' _ q ss7 <br /> PHONE#2 Ea. BOS:DISTRICT LOCATION CODE: <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOuESTOR <br /> B <br /> J O r SA / N IBILLING PARTWC� <br /> BUSINESS NAME PH NER Fzr. <br /> _f}CTlgn/ "? <br /> MAILNG ADDRESS FAX# <br /> N, GLA s civ r p-A L/AI — 70'6 <br /> CITY 5-1-0( 07W (4 STATE LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge ural all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed 10 me or my business as identified on this form. <br /> I also cer tly 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. n // <br /> APPLICANT SIGNATURE: // J/ DATE: �f /J3��-0//yy/ <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHERAUTHORIZED AGENT k VI !/V✓. 4-7 <br /> /IArmcAvrhno1ft BiurcP.vrn:proorolsuthorisaUon to sign is mquhvd ille <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operatorof the property located Billie above site address,hereby authorize the release of <br /> any and at results,geoledhnlQl data andfor environmentallsite assessment information 10 NC 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: <br /> COMMENTS: <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: DATE: <br /> ASSIGNEDTO: re EMPLOYEE#: D 3Z/ DATE: 61( <br /> .Dale Service Complete (if already completed): SERVICECoDE: 040 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br />