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SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST <br /> OWNER I OPERATOR ID <br /> �b5� c �`� �� L BILLING PARTY <br /> FAaLrry NEAKE <br /> �(� <br /> SITE ADDRESS L/�Y <br /> u NC �� a4 tHm6r aractlon SuetN+md To. Suit* <br /> Mailing Addr ss (If Different from Site Addressi <br /> Cmr F'g, di/.� STA� ,�( zip <br /> PHONE#1 <br /> C•/Tr !'Cfst. APN 0 LAND USE APPLICATION 0 <br /> PHONE#Z BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQIIFSTOR BILLING PARTY O <br /> BUSINESS ME �. -... - - --- Pin)y <br /> � �,� - <br /> MAILIIIG4DDRES ( r V r�L� FAX <br /> Gn ^1/�-n t l?� - PLv� <br /> CITY S M�,�U1� 0 l L Cl— STATE(7 ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or busines; 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 certity that I have prepared this application and that the work to be pedo will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Co es,Standards,STATE and <br /> FEDERAL laws. u'/ <br /> APPLICANT SIGNATURE: "O DATE: <br /> PROPERTY/BUSINESS OWNER 1-/OPERATOR I MANAGER OTHER AUTHORIZED AGENT O <br /> d APPuc wr is 0 rhe @ t�M P�ttrl.prool of aurhoruetlon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above she address,hereby authorize the release of <br /> any and all results,geotechnical data and/or envlronmental/sile assessment into mation to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at die same bine it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 6*0�Cts' <br /> COMMENTS: <br /> �- �i�Lgtidb '� Gt�i!sci<s� �,rr✓iGLr�v6 �u�6�ik.>,T .,---� <br /> PAYMENT <br /> JUN 2 8 <br /> SAN 10/+JUIN(;VUN f1 <br /> PUSUC Ftp >,LTH¢F_FTVI(,ES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: ENWAONPA"N i AL Hr TH DIVI <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE I�: D P DATE: <br /> Date Service Completed already completed): SERVICE CODE: �11 <br /> Fee Amount: Amount Paid Payme �g <br /> Payment Type ✓ Invoice 9 Check a Received By: ` <br />