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r <br /> T ' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#(� 4TYg <br /> r a t l A-S O L I /.t SK- ID�(C)OWNER I OPERATOR <br /> At-j31rL- f l� S0AI>aO�tt- �uILLO-( - FrzA.4Ct�4tSEES <br /> FACILITY NAME <br /> QvtV- 5TotP vtnc,17-r4p, / 3 <br /> SITE ADDRESS (Al E s <br /> 3 S !�-9— Street Number Otrecrian Stink Naim <br /> Type Suite! <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 T• APN# <br /> LAND USE APPLICATION# <br /> PHONE#2 EXT. OS DISTRICT LOCATION CODE <br /> (CIO) 45-- i i 9' S <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY 0 <br /> BUSINESS NA1AE PHONE# »• <br /> �.(/Ac,'�o4 E>��� � ���zt,l�, gee , <br /> MAILING ADDRESS FAX# <br /> P. 0 • 60 iozs 41 - rl � 2i <br /> CITY �S -�— S�IZ.. AIM S STATE C ^ Z!P r / q 1 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge Uint 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 IawS. <br /> APPLICANT SIGNATURE: �— DATE: S' / O 1 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT T rL—A-C--T—()-I.._ <br /> 1f AParc wr is na!the Bu ng Perm proof of authorizatlon to sign Is mulrod Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,t,the owner or operator of the property located at the above site address,hereby authofte the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTTI SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> SAN IN COUNT <br /> PUBLIC HEAILTH ERVICE4 <br /> ENVIRONMENTAI HEALTH PIV1QW% <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVEDBY: I ESIPLOYEE#: ( DATE: <br /> AsSIGNEDTO: /� EMPLOYEE 9: l DATE: <br /> Date Service Completed (if already completed): SERVICECODE: P I E: <br /> Fee Amount: ' <br /> -2� ( � Amount Paid �a Payment Date <br /> Payment Type Invoice#' Check# !��3 Received By: <br />