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SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Ft <br /> Business or Property !� EF <br /> BlLL1HG PARTY OPERATOR <br /> � <br /> FAcILr1y NAME <br /> SITE RES - ( I Q V..y�,C NameC TV01 Sol$ <br /> S Strut Numbs Dlr-- . <br /> Mailing Address If Different from Site Address) <br /> CITY a STA7a~e ZIP j..,2 <br /> Z�i <br /> I CleVAen1�5 <br /> PHONE#1 APN# LAND USE APPL3CATION# <br /> 7 BOS DISTRICT .` LOCATION CODF <br /> PHONE#2 <br /> Y 1 <br /> F <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> BUI NG PARTY 0 <br /> RE4UESTOR <br /> � PNOHE# Err.NAME <br /> �ttit <br /> MAILINGADORESS FAX# .•. Z 3 <br /> S 3 S.� Sslav�Ii vl�c• <br /> CITY w STATE tip <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION hourly charges associated with this project or activity will be billed to me or my business as identified an 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 JOAouIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. / rI <br /> APPuCANTSIGNATURE: DATE:, <br /> PROPERTY BUSINESS OWNER fl OPERATOR/MANAGER 0 OTHER AuTHomzED AGENT 17_ �r IWL E Ada.PC_ <br /> II ArPLcmr is not rhe IM rase.PAMY.proof of authorization to sign is mqukvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1,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 environmentallsite assessment information to the SAH 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 REQUE • <br /> c%&/ SosL rx`a�G` q <br /> COMMENTS: (y_ ,?�v O <br /> -I d C 7-S p'�YNjENr <br /> VE p <br /> L�zf APR <br /> z <br /> 2001 N` A <br /> 20®y <br /> PUF�0Ul1co <br /> FVRpNAiftVLLI <br /> � <br /> 1V <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEC#I: DATE: " D, <br /> ASSIGNED TO: <br /> EMPLOYEEfI: DATE: <br /> bate Service.Completed. (if already completed): ✓�� t SERVICE CODE. PIE; <br /> Fee Amau1T#: moun <br /> j 7c.�_ v D At Paid Payment Date <br /> Payment Type Invoice>f' Checkedr 2 <br /> 331 � Receiv8y: �J <br />