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SERVICE REQUEST <br />Type of Business or Property <br />� a2 �-f" � F 2 <br />FACILITY ID # <br />BUSINESS NAME <br />LC_ <br />SERVICE REQUEST <br />PHONE # UT. <br />� � � � <br />StLobi (� <br />OWNER OPERATOR <br />MAILING ADDRESS <br />BILLING PARTY 0 <br />FACILITY NAME S V� <br />FAX # <br />S"sy_ 44y-f73,�' <br />CITY� <br />$READDRESS <br />StrntNum6K t <br />STATE c ZIP 3 � <br />C{ I Z <br />Mailing Address (If Different from Site Address) <br />Type suN.9 <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2T• <br />BOS:DISTRICT <br />LOCATION CODE' <br />REQUESTOR <br />L—�2 2 <br />� a2 �-f" � F 2 <br />BlLLWG PARTY 0 <br />BUSINESS NAME <br />LC_ <br />5�=2�.�FS <br />PHONE # UT. <br />s{D - y�- <br />MAILING ADDRESS <br />FAX # <br />S"sy_ 44y-f73,�' <br />CITY� <br />STATE c ZIP 3 � <br />C{ I Z <br />MILLING 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 project or activity will be billed to me or my business as identified on this form. <br />I also certify that I have pre this this application and that the oris to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. y <br />�APPUCANT SIGNATURE. DATE. 3 r 2 l <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT ,D S1 -W -'4--f Tf,r F4 <br />IfApmr,wr is not ft Bum PARtY proof of authorization to sign Is required Titre <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 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 environmental/sile assessment information to the 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: NCL <br />i <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />APPROVED BY:. Q <br />ASSIGNEDTO: l. <br />Date Service Completed (if a ea y completed): <br />Fee Amount: .aG ( CI <br />Payment Type Invoice # <br />PAYMEN j.. <br />RECEIVED <br />SAN JOAUUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />^iVIP0Nh4FNTL1 HFAITHDIVISIOri <br />CONTRACTOR'S SIGNATURE: <br />EMPLOYEE #: <br />iCD' LO�! V DATE: <br />EMPLOYEE 9: �DATE: SERVICECODE: <br />PIE: <br />( <br />Amount Paid Payment Date <br />Check # <br />C <br />Sl Re eived By: <br />