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0 SERVICE REQUEST 0 ' <br /> Type of Business or Property FACILITY ID# { <br /> SERVICE REQUEST# <br /> cucrr�r <br /> OWNERI OPERATOR BILLING PARTY❑ t <br /> 0 ,, <br /> FACILrTY NAME <br /> SITEADDRESS <br /> 9 3 s+r..eNam� TYa� Svrt�t <br /> Halling Address (If Different from Site Address) <br /> CrTY STATE Zip <br /> i PH0NE#4 Ev. <br /> APN# LAND USE APPumiou# <br /> X4 Igo—Iz -�(Q -D <br /> ' <br /> [PHOKIE#2 1j05;DISTTtiCT LochTtoN CODE:.' P' <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BtLLIltG PARTY <br /> BUSINESS NAME PHONE# En. <br /> MAILING ADDRESS <br /> D f�O7 FAx# <br /> CITY 2G O STATE G• ZIPS r <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same;acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES EwRCNmENTAL HEALTH DIVISION heurty charges associated with this projec(ar activity will be billed tome or my business as identified on this form. <br /> I also certify that I have prepared this a 'gtion and tha a ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordtnanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DAA: <br />` <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR IMeWAGER ❑ OTHER AUT}ioRi=AGENT <br /> 1fAaP[kwris 'theBRtproof ofautharizadontosign IsMukvd rills <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,f.the owne r or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnicai data andlor enviroamentallsile assessment information to the SAN JOApUIN COUNTY PUBLIC HEALTH SERVICES ENv1RONMENTAL HEALTH DmstoN 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 /> 5Tu.D �lll�Ei1 <br /> COMMENTS: <br /> PAYMEN-F <br /> RECEIVED <br /> JAN 5 2001 <br /> SAN JOAQL',N COUNTY <br /> EiHEALTH SER�7CES <br /> INSPECTOR`S SIGNATURE: CONTRACTOR'S SIGNATIJRE: A'HEATH I SION <br /> APPROVED BY, EMPLOYEE—M DATE: <br /> AsSIGNEDTO: O ���� � EMPLOYEE#: �3�C� DATE: <br /> ii Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amounl: ' Amount Paid 4- Payment Date <br /> Payment Type Invoice#' Check 9 ���� Received By: <br /> o� —3a. .� 23 I�zy�, -W �/ <br />