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SERVICE REQUEST <br /> Type of Business or Property- FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR � ) / „n ,� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �;2L e I =�� <br /> HOME Or MAILING ADDRESS'(If DifferyDt,frppt S0 STATE"Mite Ad ess) c�au streat Name <br /> " � '6 �f) <br /> CITY Ate/ �r 1n 19 �zip <br /> I <br /> PHONE#1 T APN# T I LAND USE A.{PIPLTICATION# <br /> 0 '� <br /> 1 &0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR til <br /> REQUESTOR CHECK If BILLING ADDRESSED <br /> BUSINESS NAME PHONE# E'er <br /> zo 3!1 - 52 <br /> HOME or MAILING ADDRESS — FAx# <br /> -2 tzo ) 934 h <br /> CITY STATE ZIP 9524 v <br /> n . <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> \f�.PPLICANT'SSIGNATURE: , L. ��— DATE: /7- 06-01 <br /> J PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ HER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environnmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it Is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 5 <br /> COMMENTS: ,•J (f ,6 Z PAYMEN"i <br /> 2( . i WDA /*41 REM\/r ' <br /> DEC 2 8? 191 <br /> 7'r02*-''t-�/ .f' G4.GC /G�'�les•' 8��� 9.SAN <br /> 'L PUBLIC Hr.. <br /> APPROVED BY: �� EMPLOYEE#: 10 / DATE: I <br /> ASSIGNED TO: Y EMPLOYEE M G� DATE: <br /> Date Service Completed (if al ady completed): , fJ. SERVICE CODE: 3 S PIE: ,O� <br /> Fee Amount: -7 Amount Paid ;I�i Payment Date �' ,Q/L, 1 <br /> Payment Type „' Receipt# Check# �:.;i,.,,- Received <br /> EHD 48-01-010 <br /> 7/1/1999 <br />