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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# E REQUEST <br /> SE # <br /> S(Loo-,-�S-a3 <br /> OWNER OPERATOR UNG Ptt❑ <br /> 41 <br /> FACILITY NAME <br /> SRE ADDRESS �I :)— �--(/��wNumbw Dkr can Ll C- 6Y l 'l SvW Nrms <br /> SUNu, <br /> Mailing Address (If Different from Site Address) /] <br /> CITY � STATE ZIP <br /> PHONE#1EV. APN# WlO USE PLICATION# <br /> ( ) <br /> PHONE#2 FAi. BOSDISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> F <br /> UESTOR BIWNG PARTY'INESS NAME PHONE#ZwG - ZVADDRESS FAX# <br /> Gr o( Lam` C STATE LP (2/ 6 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business own ,operator or authorized agent of same,acknowledge that al site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated w Nit 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 application and that the wpik to be performed will be done• accordance with all SAN JOACUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: _ I f — l <br /> PROPERTY/BUSINESS ER ❑ OPERATOR! ACER ❑ OTHERAUTHORrrEDAGENT ❑ <br /> IIAPn1cwrlsmtNa BurcPAmv poololauthodx2don to sign Is requhvd rilla <br /> AUTHORIZATION TO RELEASE INFORMATION:When appl• ble,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaltsile ass ment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon <br /> as it is available and at the same lime it is provided to me or my resentative. <br /> TYPE OF SERVICE REQUESTED: i ,7ti6 <br /> V 3 �Y I..LS <br /> COMMENTS: 1 "`�`�-T/ <br /> RECEIVED <br /> JAN 1 1 2001 <br /> SAN JOAO LiHSU ghtir: <br /> ENVIRONMCt)Te1 FhK 11 14 <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: O DATE: <br /> ASSIGNEDTO: ��1•� EMPLOYEE 9: 0 r DATE: <br /> Date Service Completed (if already completed): SERVICECODE: TT '- 2-3b <br /> Fee Amount: Amount Paid 7rL� / C?6 Payment Date ,) _ b <br /> Payment Type N C,6pl Invoice#' Check 0 a C)3 Received By: ��� <br />