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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICEREQUES <br /> OWNER/ OPERATOR <br /> M�vlKA 17�/1` I�` CHECK If BILLING ADDRESS <br /> FACILITY NAME � <br /> SITE/ADDRESS ON66 <br /> Street Number Direction f ' Street Name Tyve Suite 9 I <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 'JOGI E. OjDM <br /> CITY STATE ZIP <br /> L-0-4C,l't Z"?-'Co <br /> PHONE#1 EXT. I APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Z�1 �yy /• , rr, 1� CHECK If BILLING ADDRESS <br /> BUSINESS NAM l l w,lJ`I PHONE# EXT. <br /> Yvc�.K� " �. "(1 .&)q ) <br /> HOME or MAILING ADDRESS FAX# <br /> 4618 i-� -1� U-, SUI AD-P< (-zoct ) 4-1(o--CASS <br /> CITY Isfuy✓)o STATECp,, ZIP ci'S21(� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and`or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �d 'L'yz C, ,y DATE: <br /> d <br /> PROPERTY/BUSINESS OWNER OPERATOR/NIANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmental/site assessment <br /> uiformation to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH 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: 2= - <br /> COMMENTS: � RFC-F— 9ED <br /> JUL 9 I <br /> SAN JU.\uUIN C UUNTY <br /> PUBLIC TH SEVICES <br /> ENVIRONA ENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> A'OROVED BY: w EMPLOYEE#: G3 i DATE: �J <br /> ASSIGNED TO: ` EWIPLOYEE 0 DATE: <br /> Date Service Completed (if already completed): ,{/ SERVICE CODE: SG !)' 2 P 1 E: �20 1 <br /> ILF,-e Amount: �� Amount Paid v Payment Date ! <br /> ayment Type Receipt# Check# Received By: <br /> S RREQrev.doc f`I 7/1/1999 <br />