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SERVICEREQUEST <br /> Type o Business�c��g;rty FACILITY ID C SERVICE REgUEST» <br /> OW RIO P T <br /> BILUNc PArrTY❑ <br /> r r v <br /> FACILIT" AME <br /> SrTEADOR 0 ILL} ( Se <br /> �"IN�ia.r hw sun. <br /> MailirIAddress (If Different from Site Address <br /> 300 — /Z(,9 <br /> CITY STATE ZIP <br /> PHONE�� APN it LAND USE APPLICATION 9 <br /> PHONE#2 CIT. BOS DU"1RICr LDumN LADE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REnu BILLING PARrX <br /> BUSINESS NAME PHONE# [v <br /> !( nn <br /> MA�D FAxS <br /> Crtt STATE ZIP <br /> r <br /> BILLING ACKNOWLE EMENT: I, the undersigned property or business owner,operator or authorized agent of same, adTaMedge that all site and/or project speck <br /> Puauc HEALTH SERVICEs cto ENTALTN OMS"houry es associated with Me;projector atth*wia be blued m me or my business as identified on N¢form <br /> l atso caru/y that I nav pro is pp that the vw be need WA be done in aannlance wM act SAN JoAQuw CC4a(7Y Oryinence Codes,StandeNs,STATE aM <br /> FEDERAL laws. <br /> APPLc.kw SwAATuRE: DATE: /�� y /' / �,/ <br /> PROPERTYI Bus,NEss OMNER ❑ OPEFATCRIMANAGER ❑ OTHERAUTHORUEDAGEMT }- (�C�—LI li7��r Klein f'22rer, <br /> 9APn aPams Battsprcarafaad"budon to&i Ppb Titte <br /> AUTHORIZATION TO RELEASE INFORMATION:When aPpkabla,L the ewveroraperatoraf the pmpaq basted atibe abvre site address.hereby auModze Gro rebase of <br /> any and all results,geotechnical data a(E "ertViIQMlattaYslfB assessment infannaDon b ele SAN JOAQUIN COUNTY Ptrauc HEALTH SERVICES ENVRONAeaAL HEALTH DMsioN w soon <br /> as A Is available and at the same time R is pr/ova ided to me or my represmfabvo. <br /> TYPE OF SERVICE REQUESTED: <br /> PAYiVIEN" <br /> RECEIVED <br /> -JUN 0 9200"i <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROYED DY: EmPLCY_—¢, .. UU DATE: <br /> ASSIGNED TO: MPLOYEE$: I . DATE: <br /> �o � E <br /> y`L <br /> Date Service Completed (If already completed): SFRVICEOODE: 52— I PIE: L <br /> Fee Amount Amount Pa d <br /> Payment Date <br /> Payment Type Invoice it Check 0 Received 8 <br /> 611Z/61 bFra <br />