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SERVICE REQUEST • <br />Type of Business or Property <br />FACILITY ID # <br />BILLING PARTY <br />SERVICE REQUEST # <br />R Err A t te (\'A- S 0 L 1 P -L ( <br />PHONE# <br />EXT. <br />'3}3 <br />L <br />5 (Z 1 2�� <br />OWNER OPERATOR <br />BILLING PARTY 0 <br />- I <br />MAILING ADDRESS <br />p•a• $01C (ozS <br />FACILITY NAME <br />FAX # <br />9t <br />$READDRESS <br />S <br />WT <br />��Ii ArNLT L/tilt: <br />C <br />Z!P C, S 6 Q <br />2D , <br />Strut Numbs <br />Wrection <br />Strw Nxn4 <br />Type <br />Svtts t <br />Mailing Address (if Different from Site Address) <br />DATE: <br />2 Sob q V I IL t KC S T - <br />ASSIGNED TO: ( <br />CITY 4 A , / w N ,,, }��'�l� <br />`( <br />STATE A ZIP � Y <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />('710) Z- - Seo 0 <br />SERVICECooE: <br />PHONE #2 UT. <br />BOS;DISTRICT <br />LOCATION CODE . <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />yYl l C u Ar, r-- t_ (/(%A L i O <br />fZF��-fzo F � i <br />BILLING PARTY <br />BUSINESS NAME 2vr <br />Ac <br />(,llTo� E+�C.t*(EF�lt ,c . <br />PHONE# <br />EXT. <br />'3}3 <br />�ECF�vE <br />914 <br />- I <br />MAILING ADDRESS <br />p•a• $01C (ozS <br />FAX # <br />9t <br />3-+3- tl�L <br />CITY W — S A -C fZ A, vtA, r-- <br />STATE Ce A <br />Z!P C, S 6 Q <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC 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 />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 COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL Laws. <br />APPLICANT SIGNATURE: DATE: 6 Ito O 3 <br />PROPERTY/BUSINESS OWNER 0 OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT 'B( COQ Q--c-T-orL- <br />IfAPPt,Gwris noI tha BtivrcPurrr proof of authorh2don to sign is raqulrad Titto <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 environrnentailsite 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: <br />UST <br />fZF��-fzo F � i <br />COMMENTS: <br />�ECF�vE <br />�uN 1 g 2003 <br />AQUIN GOONTY <br />NTALTHE lRN1DMStON <br />ENV RONto <br />INSPECTORS SIGNATURE: <br />CONTRACTOR'SSIGNATURE: <br />APPROVED BY:. ;I <br />EMPLOYEE #: �j /,� / <br />"`CCC3 <br />DATE: <br />ASSIGNED TO: ( <br />EMPLOYEE #: 7 9'0 <br />0 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECooE: <br />p / E: c <br />Fee Amount: <br />Amount Paid b-� _ <br />Payment Date U 3 <br />Payment Type <br />Invoice #' <br />Check # 3 <br />Received By: <br />I <br />