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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE/R,E/Q\UEST# <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> LA PGULM G�NittiTt- Lt_ <br /> FACILITY NAME O <br /> SITE ADDRESS,Aq ��.•c .� C r <br /> (P "J StrulN mbw eirecuan (�t� SVWW N• TYp• Sult•0 <br /> Mailing Address (If Different from Site Address) <br /> C"5-lw C-V-TO� CS�TE ZIP <br /> l �p sZ o <br /> PHONE 91 APN# LAND USE APPLICATION# <br /> PHONE#2 Esr. BO , I LOCATION CODE <br /> S.� <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> W <br /> „ , y A— BwwGPARrya, <br /> (�z.t�-t I NL c�tirli-@-artp.ri. <br /> BUSINESS NAME / PHONE# EST. <br /> 7TIOT 4fel`5 ZS Z <br /> MAILING ADDRESS FAx# <br /> �a�rG190,, ^i� —CC�•�t'l'Oh9'— - (0 7i " •Zj5l�7.Z.... <br /> CITY �fL )VIN CA, STATE LP _1sJ(P-Z_—'BILLING ACKNOWLEDGEMENT: I, the Undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project Specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this projector 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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: (�' p <br /> PROPERTY/BUSINESS OWNER ❑ OPERATORI"AGER ❑ OTHER AUTHORHED AGENT I_11 <br /> '( �nN�_ n--•�np_... <br /> IIAvrrswra no(dProof oor ofauthorvadon to sign lsmquired Titla <_l <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,[.the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all reSUl6,geotechnical data and/or environmentallsite assessment information to the SAN JOAQIIN COUNTY PUBLIC HEALTH SERvICEs EwiRoNMENTAL HEALTH ONrsmN az soon <br /> as it is available and at the same time it is provided to me army representative. <br /> TYPE OFSERVICE REQUESTED: <br /> COMMENTS: <br /> �FA'T'Y�QQ <br /> F� -t7'Evsi�L`'�h <br /> INSPECTOR'S SIGNAT RE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. Z� "-- payment <br /> DATE:ASSIGNEDTO: . IDATE: ( (�Date Se vice Completed (if already completed): ICECODE: o p f E: 23Fec Amount Amount PaPayment DateSPayment TypeInvoice#' � Receiver'By: <br />