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' SERVICE REQUEST <br /> Type of Busines r Propert FACILITY ID SERVI[,,E REQUEST# <br /> OWNER/ OPERA OR , ) <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME -;7C / 1 <br /> SITE ADDRESS <br /> / — SIrSSS�SIRLSL_��SAC9S1!4 St[SSI���� "" � Tvoa I Suitaa <br /> HOME or (LING ADORESSc If�rent t m Ile Ad ss) <br /> /(�1 G <br /> CITY n � .�/1 STATE ZIP <br /> PHONE 91 {� ) EXT. APN jj LAND USE APPLICATION N <br /> > 9y� -91/5 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO CI4ECK If BILLING ADDRESS <br /> BUSINESS NAME r / U� '`/' K) pHp11E�� �1` Exr. <br /> e331 <br /> HOME or MAILING ADDRESS FAX <br /> ' <br /> CITY <br /> STATE ZIP 2�LC1 f_ <br /> ASAI 1 ANG aC KNONVI.EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUUI-IC fIEAI.TH SERVICES ENVIRONMENTAL IIEALTII DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this aplication and that the work to be performcd will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: f � DATE: <br /> PROPERTY/ BUSINESS OWNER OPERATOR!MANAGER OTHER AUTHORIZED AGENT <br /> !f APPLIC.INT is not the GL(NG L4RTY proof of authorization to sign is required Title <br /> AIMIORIZ TION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize die release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTII DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. n � <br /> TYPE OF SERVICE REQUESTED' , � V i Y� 1 �� �( �( � P Vn A�n I r <br /> COMMENTS: <br /> F _—i RECEIVED <br /> JAN 1 0 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE' <br /> APPROVED BY: � ` EMPLOYEE : /+ j DATE: <br /> I <br /> ASSIGNED TO: EMPLOYEE DATE. <br /> AQ <br /> Date Service Complotod (if already completed): <br /> ESERV)CHECODE: I*oi <br /> Feo Amount: t -- Amount Paid Payment Date <br /> Payment Type Receipt 9 Check tf 45gLi : <br /> SIRE rcv doc 7/1/1999 <br />