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0 . <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# <br /> SERYICE�RBQ�UEST# <br /> OWNER I OPERATOR Z c <br /> !� 1 D 'f p y Lp� BtttaNG PARTY <br /> FACILITY NAME <br /> G - OUEtZ � <br /> SrrE ADDRESS l�Vl r <br /> str�nHumC.r pU � �v1-�-� �Dl�'T <br /> Mailing Address (if Different from Site Address) sw�tNa�ni :Ty=p. s'�Iut <br /> 1ZIZ90 E. CoMsTo tic n <br /> CITY <br /> L)0 D-r--tJ STATE Lp I <br /> PHONE 97 APN# qZ <br /> ('V) LAND USE APPLICATION# <br /> PHONE 92 EXL <br /> 09 D3D-1 MS- 01- 17 <br /> Bos DmimcT <br /> E, t OCAxmOH CODE' <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REaUESTOR <br /> 13UMG PARTY❑ <br /> BUSINESS NAME . <br /> Yl PHONE# Exr. <br /> MAILING DRESS <br /> '4d- r FAX# <br /> CITY L'ADCJUJD <br /> � STATE zip <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or prniect specific <br /> PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated With this projector activity will be billed to me or nTy business as identifted on this form, <br /> I also certify that I have prepared this application and That the work to be performed wil <br /> FEDERAL taws, l be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> APPLICANT SIGNATURE: <br /> DATE:— <br /> PROPERTY/BUSINESS OWNER <br /> ATE:_PROPERTY/BUSINESSOIYNER 0 OPERATOR/MWGER 0 OTHERAUTHORIzEoAGENT <br /> 1(APar-wrj;rWU)0pUM prvo(of C <br /> aulhoruagon]a sign is rnquirvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When appfcabie,I,the owner or operator of the property faceted at the above site address,hereby authorize the release of <br /> any and all results,geotechnical dela and/cc provided <br /> to me or <br /> r my assessment infom>ation 10 the SAN JOAQUIN COUNTY PUBLIC HEALTIt SERVICES ENVIRONMENTAL HEALTH OMSION as soon <br /> as itis avaitabte and at the same time itis provided to me army representative. <br /> A <br /> TYPE OF SERVICE REQUESTED: <br /> 'b 1 — s <br /> COMMENTS: 1117161 ✓" f �^f f�VIP'✓ <br /> PAY fv <br /> IT- <br /> 10 pg 240 <br /> r ----- r-7 <br /> SEP <br /> / yH V' <br /> ,��U3�tr^HY�1 <br /> INSPECTOR'S SIGNATURE: <br /> APPROVED BY:. <br /> CONTRACTOR'S SIGNATURE: <br /> EASPLOYEE#: �� E DATE: / <br /> ASSlGNED•T0: E J< EMPLOYEE#: DATE- <br /> Service <br /> I �• <br /> DATE: <br /> Date Service Completed (if already.completed): _ L <br /> Fee Amoultf: �� T SERVICE Coae: ,=�-Z . :P I E:: d{ <br /> r Amount Paid I-1 10 . , <br /> PaymentType C tnvoicet< <br /> OawM Payment Date <br /> Check ft <br /> 2402- }- Received By: / <br />