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t <br /> SERVICE REQUEST <br /> Type of Business or Property r,f 1FACILITY ID# -TFPI'-Y -x SERVICE REQUEST# <br /> � 1 .R-A <br /> t4105 .�:eS o =e c>7 Dlris;�.` <br /> CAl'TLCiVAZ-1\G LP.c.r� c-o3-3 -nF, <br /> OWNER I OPERATOR -714 o M A`s ZLK-K E R N1 A t i• BILLING PARTY O <br /> FACILITY NAME 5R(r YF-LL_-1 .A L A K T-�-i'v <br /> StrEADDRESS ZZ.SIT <br /> Street Number Direction SVeet Name TYDe SuNe/ <br /> Mailing Address (If Different from Site Address) <br /> CITY :i�TCy KZ�t••f e STATE LP <br /> PHONE#1 Exr• APN# <y`3- h <br /> APPLICATION# <br /> PHONE#2 Exr, BOS:DISTRICT LocnTioN CODE <br /> :-c r/ 4-f-,3- 733 ?, .. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR \14 AL,I€k'- � MWO C:l1 7':� BUING PARTY 0 <br /> BUSINESS NAME t•�I I`1 c�t � 1 I IFI- PHONE# EXT. <br /> MAILING ADDRESSFAX# <br /> � swe -Ztp- <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges 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 COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. ll <br /> APPLICANT SIGNATUREDATE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER IK OTHER AUTHORIZED AGENT <br /> ffAPPt,cwris ref ft B&LyGPARTI proof of aufhor&atfan to sign is required rifle T- <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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: <br /> RECEIVED <br /> MAY 8 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SEF±VhE' <br /> NVIRONMFNTAL HEALTH GiVI.S,• <br /> INSPECTOR'S SIGNATURE: L CONTRACTOR'S SIGNATURE: <br /> APPROVED BY'. C� 1 ` f .q EMPLOYEE#: ( DATE: 5 l o U <br /> ASSIGNED TO: i EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �:2 Z PIE: (_ o / <br /> Fee Amount: ; , Amount Paid r <br /> r - Payment Date - Vv <br /> Payment Type Invoice# Check# Received By: <br />