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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T cuc7 ryrA S �.Dp <br /> OWNER!OPERATOR <br /> 0 5 f31t.uHc PARTY� <br /> ,21 <br /> FACILrry NAME <br /> SfiE ADDRESS <br /> 9 Str*n Num6*r Otrectian Str**r Nam* <br /> Mailing Address (If Different from Site Address) Typ* SWIM <br /> CITY STATE ZIP <br /> PHONE#1T• APN# LAND USE APPLICATION# <br /> Cd "94-3 dor Iz V -dD -D <br /> PHONE 92 Fxr. BOS:D1STRi6T LOCATION CODE''. I <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTOR BTLING PARTY <br /> BUSINESS NAME � PHONE# � Er. <br /> MAILING ADDRESS <br /> Fax# <br /> CfTY ��D STATE s zip � 3 r <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same;acknowledge that a31 site and/or project specific j <br /> PusuC HEALTH SumcEs EWRONIJENTAL HEALTH DMSION hourly charges associated with this projector activity will be billed to me army business as identified on this form. <br /> I also certify that I have prepared this a tion and tha a ork to be performed will be done in accordance with all SAN Joaouw COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER O OPERATOR/MANAGER ❑ <br /> a MOTHER AMCRIZEDAGENT <br /> 111P, wro —P proaofaufhorizationtosign IsrequFnd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,t,the owner oroperatorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or enviroamentallsite assessment information to the SAN JoAOUIN COUNTY PUDLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Dmslon 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 /> iT E:vt1 <br /> F <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVEp <br /> AN 5 200, <br /> SAN JOAQU N CC)Ot4 Y <br /> PUBLIC �F ENVIRONMENTALHff tSERgfVSION <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: 7H <br /> APPROVED 8YEMPLOYEE M DATE: <br /> ASSIGNED TO: p EMPLOYEE#: o�7C DATE: <br /> Date Service Completed (if already completed): SERVTCECODE: -.[PIE: <br /> _ <br /> Fee Amount: Amount Paid .� Payment Date <br /> Payment Type Invoice# <br /> Check# la Received By: 146 <br /> 01 7/411 ! <br /> t <br />