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SERVICE REQUEST v <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR <br /> BILLING PAVI'74 <br /> Jll �. CC ,JY C alM�s G (W <br /> FAGalrY NAME <br /> SITE ADDRESS I I v aTNwMar orrec . '6—htt p • <br /> Nam. Sve.1 <br /> Mailing Address (if Different from Site Address) Trp. <br /> � ` -� + <br /> r / l!J o <br /> CITY Sjl�c !Q / STATE <br /> t J 7-ov4o <br /> PHONE#1 — APN# LAND USE APPLICATION# <br /> PHONE#2 Ear. BOS:DISTRICT LOCATIONCODE - - <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR - BILLING PARTY <br /> loin + fid f ( L� dSC>L <br /> BUSINESS NAME PHONE# Fxr. <br /> MAILING ADDRESSI <br /> OIn x## C ]U <br /> C tt O i STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION houdy charges associated with this project or activity will be billed to mo or my business as identified on this form. <br /> I also certify That I Aatre proctoredpplication and that Ih work to be performed will <br /> FEDERAL laws. be done in accordance with all SAN JOAGUIN COUNTY Ordinance Codes,Slandards,STATE and <br /> f� APPLICANT SIG DATE: <br /> V\ <br /> PROPERTY/BUSWE ER 0(,, OPERATOR/MANAGER JZL OTHER AUTHORIZED AGENT O G✓Yll CfyCC— <br /> IIAVPt,cwrisnortha0rttncP.tiro Poofotauthodaaeon to sign is mulnd THIS <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I,the owner oroperalorof the property located at the above site address,herebyauthodze the release of <br /> any and all results,geotechnical data andlof environmentaVSite assessment infomhaUon to the SAN JOAGUIN COUNTY PUauc 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 REOUESTto: S <br /> COMMENTS: <br /> 1/G,1n a3QU�iO AO�'��.c GvCI�GlizSh <br /> ///a +, r <br /> PAYMENT <br /> leJ A a s zzc--) a <br /> f/0 RECEIVED <br /> GI¢ % � Tv � T� �. a �+ T- rA r� A %T�z7P d c^r 02001 <br /> �� w 2l SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIROWAFNT4HT:;tTL,,•�V"�nu <br /> INSPECTORS SIGNATURE: <br /> CONTRACTOR SIGNATURE: <br /> APPROVED BY:. EMPLOYEE III: DATE: <br /> -AsSIGNEDTO: EMPLOYEE#: wv DATE: <br /> Date Service Completed (if already co plcted): - ERVICECODE: ,P)E: <br /> Fee Amount: —CC` Amount Paid I -�<,. Payment Date <br /> Paymer!Type Invoice#' `Check# / <br />