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SERVICE REQUEST - <br /> Type of Business or Property V>Q FACILITY 10 p SERVICE RE EST p <br /> OWNER I OPERATOR BILLOiG PARTY <br /> FACILITY NAME <br /> AAA R-t xlq <br /> SITE ADDRESSkog ) I �� Q `��—/ [� <br /> So-sq Mumor Denseen 't/ ' "1-T�'�l� gxune �1`� Tron SwNe <br /> hlalling Address (It Different from Site Address) <br /> X q ) aw � a i <br /> CITY <br /> ©P ESTATE 533, <br /> PRONE p1 En. APN If �LAAno USE APPLICATION p <br /> cool) 9�a — A15--�5 <br /> PHONE BOS DISTRICT LOCATIOIi CODE <br /> CONTRACTOR I SERVICE REQUESTOR _ <br /> VREQuEsR o BILLING PARTY❑33 X85-2I'SAME PIIONE p µr.DRESS �.1 FAXI�aOU' STATE LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business gwner,operator of authorized agent of same, acknowledge Thal all sinandlor project spedf <br /> jr— <br /> PUBLIC HEALTH SERVICES ENVACHMENTAL HEALTH DwiSiOrt hourly charges assocaled wdh Chis pm(ed a activity will be billed to me or my business as identified on this form. 0 <br /> I also caroty that I have prepar application and that New to be performed wit be done in accordance with at SAN JOAQUIN CouNTY Otdlnance Codes, Standards,STATE anll� <br /> FEDERAL laves- <br /> APPLICANT SIGNATURE: DATE: C `v <br /> PROPERTY I BUSWESS OWNER ❑ OPERATORI GEROTHER AUTHORIZED AGENT ❑ <br /> aA�ra M de Peolal wduruidoe to sign is rpo-M Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,L he owner or operator of the property located at the above site address,hereby authorize the release at <br /> any and all results,geolechnical data and/or environmentallsile assessment into matron to the S.w JGACVIN COUNTY PUBLIC HEALTH SERVICES ENYIROWAENTAL HEALTH ONISICH 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: <br /> COMMENTS: 6.Z c)-p p ' <br /> T. /"j y st-x ri is 4wi1w�.� € PAYMENT <br /> RECEWED <br /> RA�o IA O per, a sus s ,� JM 2 8 <br /> SAN JOAOLMN WUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: COMRACTOR'S SIGN/AlTURE: <br /> APPROVED BY: ,r� EMPLOYEE p; �V l DATE: �7 <br /> ASSIGNED TO: EMPLOYEE p- DATE: <br /> Dale Service Completed (it alrea compleleo(; _ _ SERVICE CODE:J G 6(� ( P I E; e/�p a <br /> Fee Amount: b !g Amaunl Pald Payment Rale <br /> r <br /> Payment Type Involce p Check a Receiyed By: <br /> ee� .e :ia'' - ..,•.. ,�$'+^r"".isiOn.9" �..-- �:7r- � - - _ �r - _'_- � ,w+;..__�...., w-..:'r$c.e - _ <br />