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SEnVICE R+aUEST 10 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F ©05-943 <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME 7c s q <br /> SITE ADDRESS 2)//r{/�/,(J <br /> `�' V�li Number (/DI'r�-ecti'an <br /> TYPE SuN•/ <br /> Mailing Address (If D' erent from ite Address) <br /> .7 <br /> Cm � STATE � ZIP —J, <br /> ry <br /> PHONE#1 �• APN# LAND USE APPLICATION# CJX <br /> PHONE#2 EXT. BOS:DISTIi1CT LOCATION CODE? <br /> CONTRACTOR I SERVICE REOUESTOR <br /> REQUESTOR � 13Il11NGPARTY� <br /> BUSINESS NAM C�7--Y'- A <br /> � �� <br /> P4l�o#���lt�l EXT. <br /> MAILING ADDRESS /ft6 ^ /.!� O� <br /> CITY �� STATE zip <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 /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 prepared this application and at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT G� <br /> If APP cmr is not the Batmrc PAmv proof of authorization to sign Is requi Title <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 environmentaVSite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 /> PECE U D <br /> R <br /> N�� 6 2003 <br /> t.riN 1000NN <br /> H�1."f N pEpA <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED DY:. EMPLOYEE <br /> #: <br /> (� ' l <br /> i� <br /> r Ir DATE: <br /> AssIGNED TO: EMPLOYEE#: <br /> �S Q DATE: (f <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:. <br /> Fee Amount: '2'7qO0 Amount Paid ��-76 Payment Date 6 , /off <br /> Payment Type /(/ Invoice#' Check# <br /> 1� �� Received By: <br />