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• SERVICE REQUEST <br /> ,Type of Business or Property FACILITY ID# _ SERVICE REQUEST# <br /> JZ E-T-A I L C A$ O L It txE �000/G <br /> OWNER/OPERATOR BILUNG PARTY❑ <br /> Q V t V 0 p VN AJZ IL F_,n-S Spq c <br /> FACILITY NAME <br /> VIIL t' 39 <br /> SITE ADDRESS <br /> _ E _ F2 I•In o nc T S T'_ <br /> 27-FIS StrettNumbv Direction StrW Name TYPE SuN�! <br /> Mailing Address (If Different from Site Address) <br /> �/S6 E►yr�2P11.LSJ- ST . <br /> crrY <br /> �2 VIA 0 M-T STATE C A ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> PHONE#2 Err. BOS,DIsTRicT LOCATION CODE' <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BUJNG PARTY❑ <br /> C W E L U/A c-'-0 4 <br /> BUSINESS NAMEPHONE# 6r. <br /> AL"1 -0►� I� C. ��EEfZ1�< , Vic . <br /> qr6 <br /> MAILING ADORESS FAX# <br /> 9f6 � 3— It:� Z <br /> CrTy (,(I - S P-G 2 A-rk E. K r o STATE �. ZIP 9 S b R If <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specfc <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Dms:ON hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and Ih the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: 4/L -)--/® Y, <br /> i <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT C O wt--If A-c,T o rL_ <br /> Il Acvucmr is not the 64im PA<rn proof of authorUatlon to sten Is Mulmd Title <br /> AUTHORIZATION 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 /> any and all results,geotechnical data and/or environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: U S I TZ F✓i—rz.0 <br /> COMMENTS: <br /> S 1—A L L A-r o n( C 1= t"r--,.W S P f L L C 0 wr A-f et E /L s Ar►-�D l�fL0 '� �� S <br /> K X I S Tr--c C. F I L L S'U V-(� S �C C�VVEL) <br /> ISE O s f s 0 rz.s 14 1,:- L L S'u VU P.0 _ SEP 3 0 <br /> 2004 <br /> SAN OAQUIN CRON OUN7y <br /> HEALTH p pARTTAL <br /> M NT <br /> INSPECTORS SIGNATURE: /7RCONTRACTORS SIGNATURE: L—�& <br /> APPROVED BY:. EMPLOYEE#: [DATE: <br /> ASSIGNED TO: e_���� EMPLOYEE#: c 'Z, DATE: <br /> Date Service Completed (if already completed): SERVICCECODE: P I E: <br /> Fee Amount: C' Amount Paid q Payment Date L7 3 D /P ov <br /> rpaym <br /> ent Type Invoice# Check# s� �', Received By: <br />