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SERVICE REQUEST <br />Typ o Ines op y <br />FACT ITY ID S IC REQU ST <br />OW R /OPE AZOR� �`n <br />CHECK If81LLINGADDRESSL] <br />FACILITY NAMft&'O,-, d <br />CITY ( "- �� STATE ZIP <br />SITE ADDRESS lgev <br />/gyp"q - (////�Lx`3,7� I Sita q <br />vc (a ' ! Tvue <br />5tiStLNllRLks Dl[SSL4 <br />_ <br />HOME or M 1 ADDREoq (If Different from Sit# Addres ; <br />. <br />CITY {" <br />/ STATE ZIP <br />CONTRACTOR'S SIGNATURE: <br />ENVIRONMENTAL HEALTH DIVISION <br />PHONE #1 EXT. <br />APN # <br />LAND USE P LICATION # <br />cD -771-1-2294(a <br />EMPLOYEE #: �i <br />DATE: <br />Date Service Complotod (if already completed): <br />PHQNE #2 tE'x�T. <br />( <br />SERVICE CODE: <br />BOS DISTRICT <br />LOCATION CODE <br />r_nNTRnrTOR / SERVICE REQUESTOR <br />REQU -LT6R ' C CHECK If BILLINo ADDRESS <br />BUSINESS <br />ExT. <br />P <br />HOME O MAILI ADOR SS /Q 1 ) <br />FAXP <br />CITY ( "- �� STATE ZIP <br />BILLING ING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sarne, <br />acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL Iir:ALTtt DIVISION hourly charges <br />associated with this project or activity will be billed to me or my business as identified on this foml. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />1 1--i— St lards S ATE and .I; EDCRAL Ws. <br />CUIJN I Y Oc c stance c e, ane ;, / cT <br />APPLICANT'S SIGNATURE: �j�jj <br />DATE: <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER <br />OTIIER AUTIIORIZED AGENT <br />` L <br />p <br />rr� A` IV' <br />1 P Tt ofoJauthoriration <br />to sign is required <br />RECEIVED <br />Title <br />if APPL/CIINT cs no1 1 re L;J"LaG AR . pro <br />AUTII0RI7A1I0N TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTIt DIVISION as soon as it is available and <br />.:.J...t fn mn nr my rrnrrcrntntive <br />TYPE OF SERVICE REQUESTED: <br />rL4.Al� <br />SffvI� <br />p <br />rr� A` IV' <br />COMMENTS: <br />RECEIVED <br />AUG 3 0 2000 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />INSPECTORS SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />ENVIRONMENTAL HEALTH DIVISION <br />APPROVED BY <br />EMPLOYEE #: /�T� t <br />DAZE: <br />Ina <br />ASSIGNED TO: 5�a7 <br />EMPLOYEE #: �i <br />DATE: <br />Date Service Complotod (if already completed): <br />SERVICE CODE: <br />P I E. Z d� <br />Foo. Amount: C . - <br />Amount Paid <br />cX� / 00 <br />Payment Date <br />Payment Type <br />Receipt # <br />Check # q,2,p <br />Received By. <br />SRRGQrcv.doe <br />7/1/1999 <br />