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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o ygn�'C� <br /> OWNER OPERATOR BILLING PARTY <br /> FACILITY NAME <br /> SITE ADDRESS <br /> C/G <br /> Q (j �l�' MNumbx e4ection `! =/ L-p� �M <br /> TYP• Sue•/ <br /> Mai Ing Addr s (If Different from Site Ajddr ss) <br /> Cm / ,q �/� • STATE LP <br /> CCc/// cit 9 5z¢c <br /> PHONE#1 rxr. APR# <br /> /��-7 �7� -7 LAND 115E APPLICATION# <br /> 1N -605� 11 L� '—ozo-1L �S �. — 7j <br /> PHONE#L BOS.DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR y /J 4 ( ��/ /n� �✓ BILLING PAATY� <br /> BUSINESS NAME //I]'//L / /�Cp— /!//}` _ <br /> ZZ/ I �L( Le PHONE# Fn. <br /> MAILING ADDRESS ( r FAX# — <br /> _ <br /> CRY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: L the undersgned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project speuric <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION houdy charges associated with this project or activity will be billed to me or my business as identified on this[on. <br /> 1 also certify that I have prepared this applicabOn and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,S13ndards,STATE and <br /> FEDERAL Laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 6 OPERATOR/MANAGER ❑ OTHERAUTHORRED AGENT <br /> IfA�ris nor de Burro Para Pmol of surhOdUdon In sign is mgWrad Tile <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,geolechnical data and/or envifonmentatisite assessment information to the SAN JOAOJIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same ume it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S yi1 <br /> COMMENTS: / <br /> PAYMENT <br /> RECEIVED <br /> DEC 0 6 2006 <br /> �fQ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> INSPECTOR'S SIGNATURE: I If CONTRACT//OIIR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: ��n DATE: <br /> ASSIGNEDTO: EMPLOYEEM S�( DATE: V <br /> Dale Service Completed (if already completed): �e SERVICECOOE: 3/ .P/E: 3 <br /> Fee Amount: Amount Paid J <br /> O 0 Payment Date 2 <br /> Payment Type Invoice 4' Check 0 - - Received By: a <br />