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I"I <br />A <br />0 0 <br />SERVICE REQUEST <br />of Business or Property <br />, l r <br />FACILITY ID # <br />YM f C 61 A-1., t_ L -r _0 r.( <br />SERVICE REQUEST # <br />�i"C'D!l lr 0 L t `Wt, <br />NESS NAME <br />RECEIVED <br />PHONE # <br />V <br />ERI OPERATOR <br />SAN JOAOUN COUNTY <br />BILLING PARTY <br />V I IL S Tro #0 «KSS <br />L <br />CONTRACTORS SIGNATURE: <br />LITY NAME <br />v l S rG �i <br /># / <br />r <br />/O Z�� <br />ADDRESS <br />9y6 <br />w �S <br />��c0OX <br />l/V 11 a- <br />LpcA(� <br />zip q S- ' <br />Zi StrutNumbu <br />Olrectian <br />Str,.rName <br />Fee Amount: � <br />Type <br />Suits f <br />ing Address (If Different from Site Address) <br />Invoice #' <br />Check # , 9CD <br />-+ E "--t-F.' P —, Slj- <br />a V t= <br />�) L (;F - V1n o "- <br />STATE zip <br />VE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />o) L Y7-z <br />oy ©<�a , 13 <br />4E#2 EXT. <br />BOS:DISTRICT <br />LOCATION CODE:. <br />CONTRACTOR 1 SERVICE REQUESTOR <br />JESTOR <br />, l r <br />BUNG PARTY ❑ <br />YM f C 61 A-1., t_ L -r _0 r.( <br />COMMENTS: <br />PAYMEN I <br />NESS NAME <br />RECEIVED <br />PHONE # <br />EXT. <br />W4 C <br />SAN JOAOUN COUNTY <br />qr` <br />3 4-� — /rs- 2_ <br />.ING ADDRESS <br />CONTRACTORS SIGNATURE: <br />FAX # <br />r <br />/O Z�� <br />DATE: °j i <br />G� 1 <br />9y6 <br />S <br />��-4-1 — (t� 2— <br />��c0OX <br />l/V 11 a- <br />STATE, A- <br />zip q S- ' <br />_ING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />.IC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />a certify that I have prepared this appli on and that the work to be performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinanco Codes, Standards, STATE and <br />:RAL laws. <br />JCANT SIGNATURE: DATE: O 3 A I O l <br />,ERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 0 C 0 Lr - -r h A tT A <br />IfAPmx,wr is not the BrtifrcPurry proof of tuthorivatlon to sign Is mqulrvd Title <br />'HORIZATION 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 environmentallsite assessment information to the SAN JOAQUIN COUNTY PU©uC HEALTH SER=Es ENVIRONMENTAL HEALTH DIVISION as soon <br />is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />, l r <br />COMMENTS: <br />PAYMEN I <br />RECEIVED <br />MAP 21 �00� <br />SAN JOAOUN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISInN <br />INSPECTORS SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVED BY:. <br />EMPLOYEE #: `l <br />DATE: °j i <br />G� 1 <br />ASSIGNEDTO:ve <br />EMPLOYEE 9: �/ <br />DATE: <br />Date Service Completed (if already completed):SERVICE <br />CODE: l — <br />PIE: Z3 <br />Fee Amount: � <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice #' <br />Check # , 9CD <br />Received By: <br />L-1 <br />r 1 <br />L—A <br />5L- <br />