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SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST R <br /> Type of Business or Property a 1 <br /> V-i NEIL''NG PARTY ID <br /> OWNER I OPERATOR <br /> Luis >4R�S��Enrci <br /> FACILn NAME <br /> SITE AO RESS I Ola Troy Sungs <br /> slant <br /> Street Humor DlncJon <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> CITY LODE APPLICATION# <br /> PHONE n I O� 3a6C)'O7— <br /> /v <br /> ( ) BOS DISTRICT LOCATION CODE <br /> Esr. <br /> PHONE n2 • <br /> :� <br /> CONTRACTOR/SERVICE REQUESTOR <br /> BILLING PARTY <br /> REQ,IF.STOR <br /> , T. <br /> PHONE� <br /> BUSINESS NAME , / C <br /> --- ----• <br /> V i��'� �. ._... FAx# <br /> MAILING ADDRESS <br /> O STATE CA <br /> ,� Zip <br /> Crn' �ZL DG= /C <br /> a es asso�ated with this project or aGtvrty wtll be billed to me or my husiness as identified on this lone. <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned prop�or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HE�LTH SERVICES ErNiRONMENTAL HEALTH DIVISION hourly t9 <br /> 1 also certify that I have prepared th' plication andp"!work to be performed will be done in a=rdance with all SAN JOAQUIN COUNTY Ordinance Codes, SlandardS.STATE and <br /> FEDERAL laws. DATE' T 7� , <br /> APPLICANT SIGNATURE: Z <br /> ol <br /> O OPERATOR/MANAGER OTHER AUTHCRLZEO AGENT Title <br /> PRQPERTY/BUSINESS OWNER H AppuUwr i utrr prop/of aut6oraadan to sign is r9W <br /> not the @SldSc�. <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 /> taysite assessment evto magon to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL.HEALTH DIVISION as soon <br /> any and all results,geotechnical data and/or envLronmen <br /> as it is available and at the same time it is provided to me or m P <br /> TYPE OF SERVICE REQUESTED: .5 eFr <br /> COMMENTS: <br /> I <br /> r3AK Jcnujt 1114 ON I I <br /> PUBLIC I'III 'Onyl(IRN <br /> ENUIROPIMEN i AL FtF,1�TM'plU1NICn <br /> j <br /> CONTRACTOR's SIGNATURE: C <br /> INSPECTOR'S SIGNATURE: // DATE' <br /> APPROVED BY: � v.11 ' L' I r t1 <br /> EMPLOYEE n: �� ' <br /> DATE: LJ <br /> ASSIGNED T0: v E <br /> /�� SERVICE CODE: t J <br /> Date Service Completed (If air dy completed): + Payment Date <br /> :mount: �� <br /> l� i amount Paid I <br /> F ae eceived By: <br /> Check <br /> Payment Type Invoice <br /> # S <br />