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SERVICE REQUEST . • <br /> Type of Business or Property FACILITY ID 9 SERVICE REQUEST# <br /> 3 r3� 001 �� <br /> OWNER I OPERATOR / „ � ' BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS ' 41tj'P I {{—_jJ�V' <br /> � � Sbwt NumWr Orraetion ` sN"Nam Typo suit 8 <br /> Mailing Address (if Different from Site Address) <br /> CITY STATE /1 Oil ._ ZIP <br /> � C __ <br /> PHONE#1 W APN# LAND USE APPLICATION# <br /> 0//oh �1 lel 'qs- <br /> #2 <br /> PHONE IMT. BOS Dlsntlt:T LOCATION CODE <br /> I - <br /> CONTRACTOR l SERVICE REQUESTOR <br /> REQUESTOR Bu jw PARTY` <br /> BUSINESS NAME PHONE ExL <br /> _ 1 <br /> MAILING ADDRESS - � �r'e � _ _ ,¢ � FAX# <br /> CITY C STATE �' I(�_. ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same,`acknowledge that ad site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL EALTH OrMiw hourly charges associated wdh this projector activity will be billed to me or my business as identified on this forth. <br /> I also certify that I have prepared . ap tion and that the work to be perfo ed wt1 be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL IM. <br /> APPLICANT SIGNATURE: / DATE: l U <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR l MANAGER ❑ QiHF.R AUTHORIZED AGENT --� Ti tf e <br /> If AaaXmr Is hat the B� d <br /> PARTY,proof Of WdWiNdOn to sign is raMk <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 andfor Bnvironrnentalfsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIA@RAL HEALTH DWION 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: <br /> PAYMENT <br /> JAN 2 5 1999 <br /> SAN JOAQUIN(;OUN'r <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVlS9 A\ <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EyPLCl'wt �i DATE: •-2�'I <br /> ASSIGNED TO: EMPLOYEE#: DATE <br /> Date Service Completed (if already completed): SERVICE CODE: -PIE:, <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Checlt# Received By: � � <br />