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SERVICE REQUEST <br /> Type of Business or Property FACILITY IDR // SERVICE REQUEST <br /> Utility Company 0 ,3 <br /> OWNERI OPERATOR BIWHG PARTY Cl <br /> Pacific Bell <br /> FAcury NAME <br /> SRE ADORESS <br /> '111 1.16w East 12th S t r e ,,— ,y„ seit,2 <br /> Mailing Address (if Different from Site Address) <br /> 2600 Camino Ramon , gnom 3FOOOK <br /> CITY STATE ZIP <br /> PHONE ryr'l EM <br /> APN# LANO USEAPPLICAwN <br /> (877) 823-9833 1233-369-22 <br /> PHONE 2 EXT. BOS DIS FXT ;•; LccATtaN CAOE, <br /> CONTRACTOR I SERVICE REQUESTOR <br /> RPQUES-rOR <br /> SUI NG PARTY❑ <br /> .. <br /> Scott Tannehill <br /> BUSINESS NAVE — PHGNE» �T <br /> MAILING ADDRESS FAx <br /> 1137 North McDowell Boulpyard - <br /> ClTY STAT r ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of sane, acknowledge that all site and/cr pro{ed specc <br /> Pueuc HEALTH SERVICES EMACNI.-NTAL HEPLTH O(VlSrA hourty Charges associated wt l tis proled or an",.ity` iU be tf ed to me or my business as idex�on this tart. <br /> I also cer&y that I have prepared the appl'icaten and that the work n be pertained wt be done in ac�d.ance with all SAN JOACuIN COUNTY Ordnares Codes,Standards,STAT and <br /> FEDERAL laws. <br /> APPucANT SIGNATURE lJA1E <br /> -7-! (v -ol <br /> PROPERTY/BUSINESS OWNER ❑ CPErRATW!MSN AGER SER ALrrA.oR=AGENT 0 A g e In t f n r P a r-i f i r' R o 1 1 <br /> tl Aaa..rsMr s ncr as P!ary prof of authai=da7 to 319713 mgii-od ri tl e <br /> AUTHORIZATION TO RELEASE INFORMATION:When appftmble,L the owner or operator of the property located at the above site address,hereby authorize the release t ,r- <br /> any and all result,geote�`tnical data artdlor emvonnentaJls3a assessment infnrrrsaticn m the SAN.10�Cu <br /> �+CCUNT(PLEL:C HEALTH SEAVias&wQvr e(TAL HEALTH❑MS;cN as sccn <br /> as it is available and at the same time itis provided tone at my representative. <br /> TYPE OF SERVICE REQUESTED: / � �I I c n <br /> Coa+stErrTs: CJ t J , PAYMEi'V i. <br /> RECFI\./EC? <br /> JUL2 02-00.1 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> FNVIRONMENTAL HEALTH ONISIOt; <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: ESIA':.'Yr= DAT.: <br /> ASSIGNED TO: Ew,,-aYE* DATE: <br /> Sl�vtcz 1000E: P/E <br /> Date Service Completed rf already completed): - 2 <br /> Fee Amount: Amount Paid Payment Date / <br /> Payment Type Invoice ( Check 9 0 Received By: <br /> � o U �.P�'�•r-t a- <br />