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T <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> OWNERI OPERATOR <br /> BIW GPARTY❑ <br /> FACILITY NAME <br /> SREADDRESS <br /> Stran Number dr�5an `L� J 1 StrM Namr TypY' SWlrt <br /> Mailing Address (If Different from Site Address) <br /> CITY ` STATE �,I� ZIP <br /> PHONE# EV APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 Ezt BOS:DISTRICT LOCATIONCODE: f <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> tz 0C� <br /> ayz <br /> BUSINESS NAME ��E <br /> 4/ �7TCQYlC!/ PNONE# el M��I I - 618- (408 <br /> MARJNG ADDRESS <br /> 74f-7s ktgrrCLI -Dr ( dE FAX It ys36 s0 <br /> \ Cn7S(o C U �.Q-w STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,Operator or authorized agent of same, acknowledge that an silo and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION hourly Charges associated with this project or activity will be billed l0 me or my business as identified on this form. <br /> I also certify that I have prepared this application and III to be performed will be done in accordance with at SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> C / FEDERAL laws, <br /> APPLICANT SIGNATURE: DATE: C,?— �7 <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER C OTHER AUTHORIZED AGENT ❑_ <br /> lrAPvt T is not the ULMRAMY prof of authodra ton to sign is required <br /> Title <br /> 1AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or apemlorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment Information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsioN 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: <br /> COMMENTS: •y�3 <br /> /1/6-1E ,ilrTRn7e-s f �N 65 q 0��q <br /> a rANKs = �boo9RuoA� 9n,IjF0'2-'09'1-N0,G,pR, Pq`' D q <br /> R�Cc54t' 1 I <br /> Cjif3-46m-e,l'atvc-5 ENVIRONMENT h=ALTH <br /> D Be p PRC-s'-&-r PERMIT/SERVICES B <br /> /O- TO )'�RCOknTrNC. SAN <br /> Sorr,g pf,yl�0li0UlNC <br /> (r(ZOLUVD UNTy ' <br /> INSPECTOR'S SIGNATURE• S�� <br /> /�+ ! 1�-.' <br /> CONRNCTOR'SSIGNATURE• <br /> APPROVED OY:. � _ O Qs EMPLOYEE#: C?t>e') I, DATE: <br /> -ASSIGNED TO: MPLOYEE#: DATE: <br /> : Date ScrviceCompleted (if already completed): - - <br /> Fee Amount: SERVICE CODE: - _ .7 <br /> P I E <br /> C7 Amount Paid j C� <_ _ Payment Date C <br /> Payment Type C-1 ., Invoice 9' Check L�LD Received By: <br /> i <br />