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is <br />SERVICE REQUEST <br />LA <br />ie of orProperty <br />�,.c S T A. c � <br />FACILITY ID# � <br />M I" Ar l✓ L W A L'f o j,l <br />SER REQUEST <br />q <br />Z�7-A(LOL11-LE-W <br />>INESS NAMEPHONE <br />WAS-i-oIrCI'tI -t C, S">�c. <br />#EX <br />916 3 <br />V5� <br />NER / OPERATOR <br />BILLING PARTY)< <br />Q Ott< STOP VKWLV-1T"S <br />c - <br />;ILITY NAME <br />oiit-row ' <br />Q J�l�{ <br />11 2- <br />Y <br />W15,51 S t+. ( R o� �r o <br />:ADDRESS <br />y S (o r -t ) I <br />Ltf L S T- <br />L A r,tE <br />INSPECTOR'S SIGNATURE: <br />-L } "y StrenNumbw <br />Vrection <br />Sm.tNxn. <br />EMPLOYEE #: <br />T yP <br />SUN@0 <br />ling Address (If Different from Site Address) <br />EMPLOYEE #: <br />Er•+.Teten. P weSf-- <br />S T R- E. E <br />Date Service Completed (if already completed): <br />f <br />�1Z <br />STATE zip <br />E IM o ►.v'r <br />Fee AmountU Amount Paid C9 C <br />S 8' <br />)NE #1 UT. <br />APN # <br />LAND USE APPLICATION # <br />►o) 41q Z Z S s <br />0 4 y- O Yo - 13 <br />)NE #2 �T• <br />BOS:DISTRICT <br />LOCATION CODE <br />40) 6 S'� - irS0 0 <br />CONTRACTOR I SERVICE REQUESTOR <br />)UESTOR <br />�,.c S T A. c � <br />BILLING PARTY ❑ <br />M I" Ar l✓ L W A L'f o j,l <br />I'tiYMEIV-I <br />>INESS NAMEPHONE <br />WAS-i-oIrCI'tI -t C, S">�c. <br />#EX <br />916 3 <br />T• <br />ILING ADDRESS <br />FAx # <br />P. 0' RX /O Z <br />9,6 335— <br />11 2- <br />Y <br />W15,51 S t+. ( R o� �r o <br />STATE C A zip <br />y S (o r -t ) I <br />.LING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that a1 site and/or project specific <br />Iuc HEALTH SERVICES ENVIRONMENTAL HEALTH DmsioN hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />>o certify that I have prepared this <br />)ERAL laws. <br />'LICANT <br />and that the work to be performed will be done in accordance with all SAN JOAouiN COUNTY Ordinance Codes, Standards, STATE and <br />DATE: 1/4 2 ( / o I <br />)PEATY/BUSINESS OWNER ❑ OPERATORIMWAGER ❑ OTHER AUTHORIZED AGENT T- rz A-(-T-c PL_ <br />BApRrmr is not the BB/ti M wr proof of authorization to sign Is requirod ' Ti tl o <br />THORIZATION 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 />and all results, geotechnical data and/or environmentattsile assessment information to the SAN JOAGUIN COUNTY PUeUC HEALTH SERVICES ENvtRoNMENTAL HEALTH DIVISION as soon <br />I is available and at the same time it is provided to me or my representative. <br />TYPE of SERVICE REQUESTED: <br />F Ll E � (� l P) Ac �� <br />�,.c S T A. c � <br />4 -rt z o N � �►2 w� r—j— <br />COMMENTS: <br />I'tiYMEIV-I <br />RECEIVED <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />'IVIRIP( '^.11T:NTAI HEN TH Plv jl int i <br />INSPECTOR'S SIGNATURE: <br />CONTRACTORS <br />SIGNATURE: .� <br />APPROVED BY:. C <br />EMPLOYEE #: <br />! v l i <br />DATE. <br />ASSIGNED TO: <br />EMPLOYEE #: <br />uuu <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECODE: <br />Fee AmountU Amount Paid C9 C <br />Payment Date y <br />Payment Type <br />Invoice # <br />Check 9 <br />73 <br />4ceived By <br />