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k•' <br /> SERVICE REQUEST <br /> 1Z <br /> T4FAE <br /> ess or Property FACILITY ID# <br /> �/�O / O _� f SE37 <br /> VICE RE,QtUES2T# <br /> OWNaT R /� �) 1 � v /o�7 <br /> Q O BILLING PARTY❑ <br /> y �} <br /> !s do�J <br /> (moi <br /> Str„IHumber Weccon C���// StrHfH��� <br /> s (If Different from Si e Address) <br /> /y STATE 7jp <br /> PHONE#1 /7 - <br /> APN# LAND USE APPLICATION# <br /> t <br /> PHONE92 Er. <br /> BOS,DISTR.= _ LOCATION.CoDE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTO <br /> Y BIUMG PARTY 0 <br /> BUSINESS NAAi- PHONE# <br /> EXT. <br /> MAILNG ADDRESS / <br /> 4:5�5g 1 �' - zeal <br /> / FAX# <br /> CITY <br /> STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the Undersigned property or business owner,operator or authorized agent of same, acknowledge that an site and/or project specirc <br /> PUDLIC HEALTH SERutccs EWROMMENTAL HEALTH DnnsloN hourly charges associated wilh this projector activity win be billed to mo or my business as idenGGed on this to <br /> I also certify that I have prepared this applicationrm. <br /> FEDERAL Idws. application and that the wo to be performed will be done in a000rdance with a0 SAN JOAOUB4 CMITY Ordinanco Codes,Standards,STATE and <br /> APPLICANT SIGNATURE: <br /> DATE:_ <br /> PROPERTY!BUSINESS OWNER 0 OPERATOR/MANAGER ❑ n RAUTH <br /> ORIZEDAGENT , <br /> IfAvvuc oris nor ft QjjM p Jy PrOOYof aufhorirjUon to slpn it muind <br /> Till <br /> UTHORIZATION TORE LEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,herebyauthorize the release of <br /> any and all rcsut's,gcolechnical data and/or environmentaUsitc assessment information to the SAN JOAOUN COUNTY PUDUC HEkLni SERv10ES E?WONMENTAL HEALTH DIvvoa as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPEOF SERVICE REQUESTED: ST <br /> COMMENTS: r3 l 1 <br /> j ���W•w fes-` ��`.' " _ <br /> °�iw ► Zs_ �L PAYMENT <br /> ` RECEIVED <br /> AUG 152002 <br /> SAN JOAQUIN COUNTY <br /> INSPECTOR'S SIGNATURE: PUBLIC HEALTH SERVICES <br /> CONTRACTOR'S SIGNATURE: ENVIRONNIEN 4AL HEALTH DIVISION <br /> APPROVED DY:, r <br /> EMPLOYEE#: —L^Zg'2 DATE: <br /> �15SIsuEDTO: <br /> GEMPLOYEE#: DATE: <br /> Dalc Zcrvicc Cor, Ld rJ ' L <br /> pfe; (if already complr.,cd1- �} <br /> $E4110E CCO I �i 2,3 O <br /> Fcc amount: P i E: <br /> Amount Paid — Payment Date �} / <br /> Payment Type Invoice#' D <br /> Check# — Received By: <br /> OK <br /> M <br />