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;ERVICE tkEQUEST <br /> FACILITY ID 9 SERVICE REQUEST <br /> Type of Business or Property <br /> (Z?e J7 IA L BILLING PARTY:13 <br /> OWNERIOPERATOR L A(\W/7 F/ <br /> FACILITY NAME - <br /> f�C-S 6T>EN C C <br /> =—ree <br /> , / TYoa Sud��SSITE ADDRESS L� <br /> Str.itNo <br /> (Z GIS Street Humor Olreetlon <br /> ,Mailing Addreses(I Different from Site Address) <br /> STATE ZIP <br /> C m' <br /> Esr. APN LAND USE APPLICATION# <br /> PHONE#1 �� Z/O --fig NO M5�-Ar 7f-t5 '7-,/ <br /> ( � �/r � /� / BO DISTRICT LOCATION CODE <br /> EA. <br /> PHONE#2 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY <br /> REQtIFSTOR <br /> PHONE X ezT. <br /> 9uslNEss N '67C <br /> MAILING ADDRESS CJ S'a T-E � <br /> I Z L C�l�LP STAT ZIP S^ <br /> G <br /> Crrr S Z� <br /> to be performed wcha es assocaled with this protect or activity will be billed tome or my business as Identified on this form. <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned <br /> or business owner, operator or authoraed agent of same. acknowledge that all site and/or project sped tc <br /> PUBLIC HEALTH SERVICES ENvtRDNMENTAL HEu TH DNISh hOU y the worR] <br /> I also certify that I have prepared pplicadon aworwill be done in ac�rdance wtlh all SAN JOAQuw COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. DATE: r - <br /> APPLICANT SIGNATURE: <br /> OPERATOR/Iv1ANA 0 OTHER AUTHORIZED AGENT <br /> � T i t l e <br /> PROPERTY I BUSINESS OWNER d ris not dw @LLt§-& Y proof of authorisadon to sign is rOWkW <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,9eQteChnlCal data andlor enwrOnmentallsite assessment into madon to the SAN JOAQUIN COUNTY PUBLIC HE41TH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: p/`j u I n <br /> COMMENTS: <br /> gay <br /> . 8 �'� <br /> LHL C '-IEA; <br /> M-iF(;�1•F•-N� a�, �'✓;c. 1i, <br /> CONTRACTOR'S SIGNATURE: <br /> !NSPECTOR'S SIGNATURE: DATE: <br /> ESIPLOYEE n: <br /> A.PPROVEDBY: <br /> DATE: <br /> EMPLOYEE R: / <br /> .ASSIGNED T0: _I _ 1 PIE: <br /> f ScR`IICE CODE: 1 <br /> Date Service Completed (If already completed): ILI. Q <br /> Amount Paid I Payment Date 6 q <br /> �� <br /> -ee Amount: ` Received By: <br /> ID <br /> Payment Type Invoice Check� <br />