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L SERVICE REQUEST <br /> of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Li NE OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACIUrY NAME <br /> SITE ADDRESS <br /> 7 {/ <br /> a Suite Id 3 /°6l <br /> °i HOME Or MAILING ADDRESS (If Different from Site Address) , <br /> CITY STATE - ZIP G O <br /> r ✓VP H <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ►.e PHONE#2 BOS DISTRICT LOCATION CODE <br /> i <br /> CONTRACTOR / SERVICE REQUESTOR <br /> i_ <br /> REQUESTOR CNECK I(BILLING ADDRESS <br /> _ <br /> BUSINESS NAME r//l/ <br /> ytOL"- <br /> PHONE# Ext. <br /> HOME Or MAILING ADDRESS FAx# -' <br /> CITY STATE ZIP / <br /> �O <br /> BILLING 4CICNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC IIEALTII SERVICES ENVIRONMENTAL HEALTif DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this form. <br /> J also certify that I have prepared this application and t t the work to be perforated will be done in accordagce With all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE ED RAL la S. <br /> APPLICANT'S SIGNATURE: DATE: O <br /> PROPERTY/BUSINESS OWNER OPE OR/MANAGER OTHER AUTHORIZED AGENT <br /> if APPLIGrNT is not the I C, .t proof of authoriLation to sign is required Title <br /> t IMIORI7ATION TO RELEASE INFORMATION: Mien applicable, T, 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 envirotunental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES ENVIRONMENTAL HEALTIf 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: <br /> COMMENTS: �` �✓'Z <br /> Itr-6-�iN S e vtr•t�— �y <br /> q F � A'e�a i/7'v�TV&, "L T7te / >�re An r�>�rrnee•�� PAYMENT <br /> /t/Qlltrd f%/� s*�?�'jPt Wtl1 (N wP tcarrd. FA tyAit- +v txisi,/ n SrgL�-1 REreIVED <br /> r reo�Nfa✓ 1/AGtt )INC wlrull �dc R//drve� IV44er -4b/C is 44 err <br /> OOV 6®1899 <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: t INTY <br /> APPROVED BY: �P`x('n EMPLOYEE#: 7 �' EN ENTA ISION <br /> L ASSIGNED TO: EMPLOYEE#: 5C`� DATE: /a1&�9 <br /> Dale Service Completed (if already completed): SERVICE CODE: © P f E: C'1 <br /> 6. Fee Amount: Amount Pald Payment Data <br /> Payment Type Receipt# Check # Racelved By: <br /> SILRIiQrcv.dce <br /> 7/1/1999 <br />