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S- 130--63 60 moo'-- <br /> h C f- G It0 _— <br /> • SERVICE REQUEST 0 <br /> Type of Business or Pro erty, FACILITY ID# SERV C REQUEST# <br /> f I � Joloi,� �a� <br /> OWNERPERAiOR t BILLING PARTYve '- <br /> Ei <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Wast Nu,na.r wemod a✓ All ryn. Suite <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#'I *• APN# LAND USE APPLICATION# <br /> PHONE#2 BOS DtsTRicT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REnuE� R � <br /> P ,S(Y- Cdr ti BURG PARTY❑ <br /> B E + PHONE# EXT. <br /> ING ADDRESS [� FAX# <br /> • G1Y �`t� ! �dr <br /> Cay 154ve, 4v4 c 16LTia STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that as site andlor project specific <br /> PUBLIC HEALTH SERVICES ENviRONIUENTAL HEALTH OmsioN hourly 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 p pa nand That the oik to erfonned will be done in accordance with all SAN JOAQUIN COUNTY rdinarrc Codes,Standards.STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: a <br /> PROPERTY IBUSINESS OMER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> if At mrI yr is not Ure Bum Pana proof of authorIkatfon to sign is raquhvd Title <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 andlor environmentallsite assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ErMRONMENTAL 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: �,5U I I —RM—t '4 � 1J Y <br /> - cv 21 r)nA <br /> COMMENTS: <br /> 7• !z • ov leevr r c 1 `'& <br /> G nd w►�_ *+ 5- PAN E VED / <br /> REC <br /> puhll e_ s-6U� 011aL, -vim IOJVI�4 /q��� SUN 3 0 2000 <br /> SAN JOAQUIN COUNTY <br /> pU5t-tC HEALTH SERVICES <br /> EN%RUNMENTAL HEALTH U VlStON <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVEDBY:, EMPLOYEEM DATE: <br /> AssIGNED TO: EMPLOYEE#: S� j DATE: <br /> Date Service Completed (if already completed): SERVICECoue: <br /> t: ��-' f <br /> Amount Paid 1i5 a a Payment Date �3 If(7 C0 <br /> Fee Amount <br /> Payment Type Invoice# Check# $.1 Received By: J <br />