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�.' SERVICE REQUEST <br /> Type of Business or Property FACILITY IDN SERVICE REQUEST N <br /> OWNER(OPERATOR <br /> Axle <br /> /x� BILLING PARTY <br /> FACILITY NAME �' <br /> SITEADDRESS <br /> straal Numbr grnyon /C �/�'� 1r5trM Namt��� iYV� s,-,Mailing Address (I(Different from Site Address( <br /> D D cit/ E.+�/f1i✓ !�.✓� . <br /> O Y ,LO f I <br /> STATE -,JLr <br /> PHONENtEar. APNN LANoUsEAPPucAT1oNN <br /> >?D� �6 r 7� O63 -oa ,��- Oy-iso <br /> PHONE N2 Exr. BOS.DISTRICT LOCATION COOE' <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR / / <br /> Bu.uNc Pnarr❑ <br /> BUSINESS NAME <br /> MAILING ADDRESS <br /> FAx N <br /> CITY /A /' STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undemgned property or business owner,operator or authorized agent of same, acknowledge gta(30 site and/or pmject spedGc <br /> PUDLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSIoN howdy Charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appli on and that the work to be performed will be done in acoordance with <br /> FEDERAL laws, all SAN JOAWIN COUNTY Ordinance Codes,Standards,STATE and <br /> JJ��® q <br /> APPLICANT SIGNATURE:: /"�^" //% �� DATE: <br /> PROPERTY/BUSINESS O+MER O OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1lAnrN,cwris not the Q/irc P.wry poorer authoriradon to sign is inquired Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I.Vin owner of operator of the property located at the above site address,hereby aulhonze the release of <br /> any and all results,gC0tCChnloal data and/or envimnmentaftle assessment information to the SNI 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 REQUESTED: <br /> 'z' l� <br /> COMMENTS: <br /> RECEI�D <br /> � pUG 4 2 2005 <br /> R3 SN IVI O DE1AN JOA NMet4l-All- <br /> vwi►✓El'�T <br /> INSPECTORS$IGNANRE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. OLfUt �/ �1 EMPLOYEE N: <br /> 032-( DATE: � (Ji GS <br /> ASSIGNED TO: J,{ 11 /' /' rnJS EMPLOYEE N: <br /> DATE: s- 0 <br /> Date Service Completed (if already completed): SERVICECQDE: <br /> =2== <br /> ee Amount: (f3-72-- <br /> SZ-2 �J7Z PIE: 2-6 ,Ul <br /> $(� L z (f 3�Z Amount Paid Payment Date <br /> Payment Type Invoice N Check N <br /> Received By: <br />