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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> f l/P,- Lui s A i <br /> FACILITY NAME <br /> A/,,, 15 McN�) I S(DCtVCJF <br /> SITE ADDRESS .-17(L L J� <br /> f I S I Street Number Direction I !� /` Street Name Type SuRe d <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> a <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• SOS DISTRICT LOCAT M CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR DatAi <br /> BILLING PARTY67 <br /> BUSINESS NAME PHONE# Exr. <br /> LA L LE —f�i4f_«/ �6 - 403 <br /> MAILING ADDRESS - O �O x �7 ,9!1 FAX# <br /> CITY L 0 C–I'L STATE C'`A zJP <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 plication an a the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> 0//;?- <br /> PROPERTY/ <br /> ?PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APDL wr is not ft 6tt1mG PA ary proof of authorizaUon to sign is required Title <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 onvironmentaVsite 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: PAYhrhtF <br /> F3Et4"#*E1VF_ <br /> OCT 2 U 1999 <br /> :"AN JOAQUIN(--)U,,. <br /> PUBLIC HEy1LrH zf''.A,, <br /> ENVIRONMENTAL HEALTH milV ,i,i <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EtIPLOYEE#: i , DATE: <br /> ASSIGt1ED T0: <br /> EMPLOYEE EE#: C_<7"3 DATE: / <br /> Date Service Completed (if already completed): 1��7 /w v SERVICE CODE' — P!E: <br /> Fie Amount: Amount Paid — <br /> $r�S(,, Payment Date <br /> Payment Type Invoice#' Check# Received By: <br />