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L <br /> * <br /> Type of Business or Property SERVICE REQUEST <br /> FACILITY fD# <br /> � 4s1�f�� SERVICE REQUEST# <br /> OWNER IOPERATOR �F-00 H 2-Co C Z <br /> 8«.LrNc PARTY�a'� <br />� FaclurY NAt�tE <br /> SITE ADDRESS <br /> I SrrfH trumb*r Olrecfran '43. <br /> Mailing Address (If Different from Site Address) N>M. <br /> TYP'AZ <br /> surr.e <br /> CITY <br /> «� 6- STATE ZIPPHONE#'l � �• APN# � <br /> LAND USE A,P/PJUCATION# <br /> PHONE#2 <br /> E"' BOS:DIsTRICT <br /> _ CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUE$TOR —>—' <br /> acne ,`/�/►�,( '� BILUNG PARTY Cl <br /> BUSINESS NAME <br /> 0"A/p4p �f�,• h PHON17 ff <br /> MAIUNG ADDRESS <br /> !/• Zai[�/ 2/g—�D FAX <br /> Crry <br /> BILLING STATE �y zip BILLING ACKNOWLEDGEMENT; I, the und=gned property or business owner,operator or authorized agent of same, acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HULTH DIVIS:ON hourly charges associated with this project or activity will be billed to me or my business a;identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will <br /> 1'EDERAL]aWS. be done in accordance with all SAN JOAQU;N COUNTY Ordinanco Codes,Standards,STATE and <br /> APPLICANT SIGNATURE: „�yy� <br /> DATE: Qom— 1i <br /> PROPERTY lBUSINESS OvrNER D OPERATOR/MANAGER (] Oi <br /> HERAUTHOR1ZEpAGEHT <br /> 1rAvrLxyrrisnotthaQu PARtt p+ooroloudwririrlonrasign Isrnqujrod <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 environment2ft(O assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICCS ENVIRONMCNTAL REACT"DIVISION as soon <br /> as its available and at the same time it is provided to me or my representative, <br /> TYPE OF SERVICE REQUESTEn: <br /> n <br /> COMMENTS: f <br /> RECVED <br /> SUN 7 <br /> SAN,yt3AG�U4N COUNTY <br /> }d I ENViRONMENxAt <br /> tiIEALTH DEPARTMENT <br /> INSPECTOR'S SIGN <br /> APPROVED BY:, CONTRACTORS SIGNATURE: <br /> EMPLOYEE#: DATE: /? <br /> -'ASSIGNED To: <br /> E thYEE k: DATE: <br /> Date Service Completed (if already completed}: <br /> SeRvmcR CODE: P I E: <br /> Fee Amount: .� Amount Paid <br /> ��7L. 0-0 Payment Date <br /> Payment Type � Invoice#' <br /> Check# �1 Received By: -57 oo,� <br /> 1l <br />