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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST R <br /> /D>✓W 77A t- <br /> OWNER I OPERATOR BILLRIG PARTY CI <br /> -- <br /> FACILITY NAME <br /> 014 <br /> Cf r'T FS/P> �C <br /> SREADDRESS qv , / 5' A ��eF AV4E <br /> 201z�a1 ZO 7191A Z Stres,Humbert— Olra@oo Su@h Nam@ —Typo Suss/ <br /> Mailing Address (If Different from Site Address) <br /> Crry STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#Z BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQIIF.STOR BILLING PAR <br /> BUSINESS NAMEIZ O <br /> t-E V. .. fJa� _... - -- --- PNE 40-3 c�T <br /> VA t <br /> MAILING ADDRESS 9 V-1 �, —2-r7GW <br /> r 'v <br /> Cmr jZLO CCL STATE A ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or busloesq owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION hourly Charges associated with this project or activity will be billed 0 MI or my business as Identified on this form. <br /> I also certty that I have prepared th pplicadon a al the work to be performed will be done in acoordanca With all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPUCANT SIGNATURE: 2 DATE: -3 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MA ER OTHER AMORIZED AGENT ❑ <br /> gAPPLcmris r0(ha Qu.MPAR proal of aurhoraadon to slpn Js rayulrad rill@ <br /> AUTHORIZATION TO RELEASE INFORMATION;When applicable,I.the owner or operator of the propaq located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or envirOnmental/site assessment Into matron to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMslory as soon <br /> as it is available and at die same Erne it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S _D/G Ste/i f�z3 Z/ - <br /> COMMENTS: l <br /> G1Kvu'urJWl}T67rY.B' 1 NrNsUfo 40¢TE42T/�13�.E; ��COL* �11���OCK 8lZ <br /> PoRTeT> REQaIRED REAuL,1E 00L*K To -FA�i�-fT Y7 tX#&5P/GZg7-10X—) dW <br /> /4 >,G SYS Tb wt (,TP So IVO CICAEp F-rr ' <br /> MAR - 41999 <br /> SAN JOAQUIN I;uuNTy <br /> PUBIlC�FQI T�SERVIGES ----- — <br /> ENVIRON ENII�TAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE M /6 �el DATE: 3 �( <br /> ASSIGNED TO: EMPLOYEE r#: /e'�4�-1 DATE: / <br /> Dale Service Completed (If already completed: SERVICE CODE: -2 PIE. <br /> ,;Z(�•C;� <br /> Fee Amount: /F6 Amount Paid qL /SIP Payment Dale 3/y(qq <br /> Payment Type Involce# Cfteck ff 51 L/ Receiyed By: <br />