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SERVICE REQUEST •._— <br /> of Business or Property - FACILITY I I SERVICE REQUEST# <br /> ER OPE i0R <br /> / r I Bwxc PARTY <br /> :MY NAME <br /> fEADORESS <br /> r strMNuMw drectiaa TTM SWUI <br /> lailing Address (If Different from Site Address) <br /> CITY ts-C'1/I..C. % � 1"v" ST Ja� <br /> PHONE#'I -n FIT. APN# LMm USE APPLICATION <br /> # <br /> -/. 7 <br /> PHONE 12 FST• BOS Dlsrmcr LOCATXIN CODE <br /> • CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTOR t g� 8N1Nt0 PARTY O <br /> lJ C `5 <br /> BUSINESS NAME '7 <br /> �. PHONE — 3/'C17 ur. <br /> HARING ADDRESS FAX# .� <br /> l �•✓ �L /tit 7_ro�� <br /> STATE <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner,operator or authorized agent of same, acknowledge that all silo andfor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION houry dharges asso63led with this pmjedor activity Mall be billed to me or my business as identified on this fame <br /> I also ce*that I have prepa plication and Nat Uhe w to 'Dedonned will be done in accordance with al SAN JOAQUIN CC; Ordinance Codes,StandaNs,STA and <br /> FEDERALlaws. <br /> APPLICIM SIGNATURE: \ DATE: <br /> PROPERrf/BUSINESS OMER OPERATOR/MANAGER ❑ On"AuTNRIZEDACENT '� (�y ur vcpwa.{•T/ <br /> IfAavtswr k not tlta osra�P,—prootofSudbodradon to sign is rmpukvd Nitta <br /> AUTHORIZATION TO RELEASE INFORMATION:When applable.L the owner or operator of the property Idled at the above site address,hereby authorize the release or <br /> any and at results,9colechnial data and/or enviionmentaysite assessment Information I the SAN JOACUN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon <br /> as it is avalaMe and at the same Ume it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: f +�-,,� <br /> v 1�0..� <br /> l�/ <br /> PAYMENZ <br /> RECEIVED <br /> \vn` W- SEP 6 2000 <br /> ` SAN JOAOUIN COUNTY <br /> c`� PUBLIC HEALTH SERVICES <br /> INSPECTOR'S SIGNATURE: <br /> IS SIGNATURE: ENVIRONMFNTAI HFAITH DPASIDN <br /> APPROVED DY:. � <br /> LO _ D .9�1 DATE: <br /> llS51GNE1]TO �! r�� lJ� <br /> EMPLOYEE k: - .DATE: <br /> :Date Service Completed (if aireadycomp e e _ <br /> 1 - - - .. <br /> Fee Amount: l ' <br /> nt Paid DE: <br /> PPaymentDatc <br /> aymentTypcInvoice <br /> �_� _�•� <br /> Invoice <br /> Check 9 ��/ �� Received 8y: <br />