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\ SERVICE R_QUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITEADDRESS ` n <br /> 8 Street Number Direction \ S SVM flan. <br /> Type Sulo <br /> Mailing Address (If Different from Site Address) <br /> LA Qenms <br /> CITY L P �`\ �� C STATE ( .CA ZIP C� V <br /> V <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2T• BOS:DISTRICT LOCATION CODE' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BSG PARTY <br /> BUSINESS NAME PHONE# <br /> 1 Z 1 Co x, r C'-tLt-v rz�." all <br /> MAILING ADDRESS ` �r' <br /> F0 �1b1 - b3�� <br /> Crnr STATE C ZIP - <br /> c <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 /> PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsicN hourly charges associated with this projector activity will be billed to me or my business as identified on this form. <br /> I also certify that I have preparedth' pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. I <br /> k APPLICANT SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1fAv xr—wris not Ux ftLtvaPfary proof of mthorizadon to sfpn Is requkvd Titte <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 environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION 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: Ll I Re )�I <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> JAN - 2 2002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SEVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. ��� EMPLOYEE 9: %l< ') DATE: <br /> ASSIGNED TO: G N EMPLOYEE 9: J DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ry —FP <br /> I E: 2 30 <br /> Fee Amount: 0 C� Amount Paid Payment Date <br /> Payment Type Invoice#' Check# Received By: <br /> V <br />