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SERVICE REQUEST _ <br /> Type of Business or Property FACILITY 109 SERVICE REQUEST# <br /> <� 00 2 713 <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> /C'lY «ems nam/i J <br /> TN.4 � <br /> swilea <br /> Mailing Address (If Different from Site Address) <br /> CITY `r .tel 1�, u C t <br /> Z ^y M `/ Z� .STATE ZIPPHONE#1 CA If <br /> APN# LAND USE APPucATioN# <br /> ( ) L P—CI- C%J — C� <br /> PHONE#2 Ear• BOS DISTRICT LOCATION CODE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR % / r - BILLING PARTY . <br /> BUSINESS NAME (/ PHONE# /' 7� Ear. <br /> 2 (o / 7 <br /> MAILING ADDRESS 0. FSC 9 9 <br /> Cay G STATE LO zw <br /> BILLING ACKNOWLEDGEMENT: I, the undersign property or business owner,operator or authorized agent of same, acknowledge that ad site and/or project specific <br /> Puauc HEALTH SERVICES ENVIRONMENTAL HEALTH DrnsloN hourly charges associated with this projector activity will be billed to me or my business as Idenbred on this font <br /> I also ceruy that I have p ared this application and that the work to be performed will be done in accordance wit all SAN JOAOAN COUNTY Ordinance Codes,Standards.STATE and <br /> FEDERAL laws. )) <br /> APPLJCANT SIGNATLAE. 1� OATH—�� Q <br /> PROPERTY/BUSINESS OWNER 'per OPERATOR/MANAGER ❑ OTHER AUIHORRED AGENT ❑ <br /> `' MAPaX. aXt Rs 81,M Pr ..proorofaedrortadm W sign is ngeed Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property iocated at Ute above site addross,hereby auNa¢e the release of <br /> any and all results,geotechnical data anchor envimnalertaYsite assessment infoni-I to he SAN JOACUw COUNTY PUBLIC HEALTH SERVICES EWRO%ENTAL HEALTH DIVISION as soon <br /> as U is available and at the same tune it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: " <br /> S 0 <br /> COMMENTS: <br /> PAYMENI <br /> RECEIVED <br /> JAN 2 9 2002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNARE: CONTRACTOR'S SIGNATURE. <br /> APPROVED BY: EMPLOY+A: / DATE• G -L <br /> ASSIGNEDTO: - It= 201 94Yi3o( EMPLOYEE#: _ 'f? DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: z — P!E_ 2k'Z- <br /> Fee Amount �".�' Amount Paid Payment Date <br /> Payment Type �/ Invoice# Check# Received By: <br />