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UUr Gii u��l i. . .,. GtIJ4 +,�:; i"lr Irl rLUiJh <br /> i��ut LJU <br /> SEMACE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST R <br /> F-A] 6o aG 002,--7 .Z-0 <br /> GWNER I OPERATOR BILLING PARTY D <br /> FAC-UTY NAME <br /> STTEA170RES5I V E A v C, <br /> 57t�t Nomhef Otnc7an sb*d Name Typ. swu 0 <br /> Mailing Address (If Different from Site Address) <br /> CRY 9 � STATE � ZIP <br /> PHOYE#1 &T APN r# LANo USE APPLl=ioN <br /> ( ) <br /> PxoNE2 BCIS DISTTucT LoCA7toH.CooE <br /> <' <br /> CONTRACTOR SERVICE REOUESTOR <br /> RE4UESTOR ulUJNG PARTY❑ <br /> BUSWESS NAMEPHONE# FXT. <br /> Tl�►/}n/(rCE �ifV#/2DNMEil7Y}L, /ti!C , 96 S40 W 2-0 <br /> MAILING ADDRESSFAx m <br /> X152 �-'/o --617,2-1) <br /> CITY UR64Al /� STATE <br /> /� ZIP q/-5vs <br /> BILLING ACKNOWLEDGEMENT:L the undersigned property or business owner,operator or authorized agent of same,acknowledge ftlat all site andfor prom spm <br /> PuauC HEALTH SERVICES Et-'AM4NENTAL HEALTH ONri1 hourly charges associated with lids projectOr actively will be billed W Ina or my business as identified on this form. <br /> 1 also cemly that I have prepared this application and that the work W be performed will be done in a=rdance with all SAN JQAOUIN CouNrY Ordinance Godes,Standdrtis,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROP5RYIBUSiNE5$O"ER ❑ OPERATOR/NW4AGER ❑ OTHER AUTHOR=AGcI4r C� DM/Nf5I7�>7�� <br /> KAmtrw1'isnot ft$AumgP prvatofwttror"66atosi rkreVirvd riffe <br /> AUTHORIZATION 19 RE EASE INFORMATION:When applicable,1,the owner or operator of the property kxamd at the above site address,hereby authorize the refease of <br /> any and ail results,geotechnical dala and/or enVimnmerIMUSite assessment InfQM1alian to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVrct S EWRONMMAL HEAL71+OMSION aS Soon <br /> as its avadaCle and at the same L7ne it is provided to foe or rry rupeSOnt cue. <br /> TYPE OF SERVICE REQUESTED: <br /> CGMMENTs: RECEIVED <br /> AUG 200 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> �wRONMFNTAI HEALTH DIV131ON <br /> INSPECTOR'S SIGNATURE: ) CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: i L�✓A�J "—06 � F�4P1'J �'rE �1 II OATS . <br /> ASSIGHEDTO: S�) <br /> EMPLOYE--9: DATE: <br /> Date Service Completed (if aIMA completed): SERVICE COOS ,.. <br /> Fee Amount- i Amount Paid Payment Date p <br /> Payment Type b>> • Invoice# Check 4_,, � '��( eceived By: <br />