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05/06/2002 09:52 4640138 ENVIRONMENTAL HEALTH PAGE 08 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> OWNER I PERATJ BILLING PARTY 0 <br /> FACfLTT'r NAME <br /> SrrEADORESS <br /> Z�-o 1 StreeiNu�K olreedan SO�ttN�ro. <br /> T714 <br /> Mailing Address (If Different from Site Addresst <br /> CITY . 5'TATS ZIP <br /> PHONE91 Er. APN# Lmo USE APPLICATION# <br /> PHONE 92 Exr, HOSEDISTRICT" .;,�; • °° -; LocApd9 COD ++ <br /> r+lL j,V.�15-,. JV:�,I••,_ .• :;wI4„4�'f�l•�,.• :R'. ' .. !�i <br /> CONTRACTOR ISERVICE REQUESTOR <br /> REOUESTOR BILLING PARTY 0 <br /> BUSINS4 NAME PHONEit <br /> &io (�(\� La f sro) �pl -1139 0 103 <br /> IIIw�INGADDRESS . PAX# <br /> CITY t V'� SYME C� ,ZIP Rgls T <br /> BIL INS ACKNOWLEDGEMENT; 1,Ute undersigned property or business owner,operator or authorized a�ent of same,acknowledge that all site andror project specir�c <br /> PUBLIC NEALTH SERV1cEs ETI uNMENTAL HEALTH Omsiott hourly charges associated with this project or adivity will be billed <br /> i7ied to me or my business as identified on this form, <br /> 1 also Certify that I have prepared this application and that the work to be performed will be done in acwrdance with ail SAN JOAOUIN COUNTY Ordinance Codas,Standards,STATE and <br /> FEDERAL IawS. <br /> APPLIcAtt'f SNGMlrurt s: DATE: <br /> PROPERTY I BUSINES$OMER 0 0P[RAT0R1MWACER 0 OTHERAUTxMz.EDAGENT 10 � <br /> BAftr,wtis not tha UILK Purr proorarauBror Won fa.716n 12 mulmd r111p <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property f)6tcd at tile*above site address,hereby authorize the releaso of <br /> any and aft results,gcoWl)nical data andtor anvironment0slin assessment information to the SNI JoAWN CeuNTY P60ue I-IMT11 SCmMES ErMrtOnmEHTAL HEALTH Dr SIGN as soon <br /> as it Is available and at the samo time it is pravided to me or my representative. <br /> TYPE of SERvice Re4uWEW `r <br /> COMMENTS: <br /> t <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY., <br /> EMPLOYEE#: C DATE: / <br /> 'ASsIGNEDTo: PLOYEE#: .DATE: <br /> „. <br /> :��Y2 <br /> Date Service Completed (if already.ccmplct4: �'4 SERVICECODfi: P.1 i::. <br /> P.. <br /> Fee Amount: Amount Paid Payment Date <br /> Payment,Type Invoice#' check# Received By: <br />