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i s <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE,REQUEST# <br /> 5(?—Cb � Q <br /> OWNER OPERATOR SlLLlNG PARTY❑ <br /> FACtuTy NAME 4 ro (7 se—ei t W V-1 6-,- S" C l a S{,:5� . <br /> SITE ADDRESS _ <br /> I (s ( LI <br /> StroK Numh�r INrettian StrM Nxn* Tt'P $UNC e <br /> Mailing Address (if Different from Site Address; I <br /> CnY /; {} STATE � zip <br /> PHONE#1 �. APN# �� �_ I ���� LAND USE APPLICATION#� 5, f ]J <br /> v f . <br /> PHONE 92 <br /> BOS:DtstRlcr LocATIONCODE . <br /> CONTRACTOR l SERVICE REQUESTOR <br /> REQUESTOR /., �,y� SSLiING PARTY❑ <br /> f✓ A2 L 4-4-L <br /> y BUSIXESSWe 43ftme- A-5 above—, \ PHONEft EXT. <br /> MAILING ADDRESS <br /> a -r_ LA-AJ <br /> a s 5n 0 FAX# 33 r $ D <br /> CITY D aq <br /> STATE /1A zip qua <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same,acknowledge that an site and/or project specific <br /> PUBUc HEALTH SERVICES ENmoNUENTAL HEALni OmsION hourly charges associated with this projector activity will be biked to me or my business as identified on 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 JOACUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. I— <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZEDAGENT ❑ <br /> 1fAPPLrMNs not ft Vg tm FAmy.proof of authorizadon ro sign is requrrod Firma <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 r <br /> any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIcCs EwLRONmCuTAL HEALTH Dmsiou as soon <br /> as it Is available and at the same time it is provided to me or my representative. <br /> TYPEOFSERVICE REQUESIED: [ <br /> COMMENTS: <br /> - - P�YN' +'VT <br /> - - RSCLIVED <br /> MAR 0 200, <br /> SAN tc.s vU.;i4 TY i <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE : t'1rlr� DATE; i1 <br /> ASSIGNED TO: EMPLOYEE#: V +� DATE: { <br /> Dale Service Completed (i alreadkjEt ee 3.t� � � � S£RVICECoDE: Pj 2 Z PIE:Z <br /> Fee Amoun#: o Amount Paid � Payment Date <br /> Payment Type invoice 9' 1 Check 9 74 Received By: �j - <br />