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SERVICE RFOUEST 6 <br />Type of Business or Property <br />BIWNG PARTY <br />FACILITY ID c <br />�A 3a <br />SERVICE REQUEST # <br />s Eez cAs s:.friO.� <br />MAILING ADDRESS <br />c <br />F.0O <br />C' - 1ER I OPERATOR <br />STATE 6. ZP -77 <br />BILLING PARTY G <br />v140AJ N>,E !'/ZiS�'S <br />C <br />FACiuTY NAME <br />SITE ADDRESS Qg� <br />G/ $treat 4umhr <br />�vrrc�on <br />` O Street Name Ty" <br />I vi rs r wz jC� <br />suite;t <br />Mailing Address (If Different from Site Address <br />600 W14 -Of X T <br />/1R <br />�rSy' <br />CITY <br />STATE Z1P <br />Q <br />PHONE #1 -'T <br />APN # <br />LAND USE APPUGArcN # <br />�93 103 <br />I <br />PHONE'»`2 aT• <br />BCS DISTRICT I LOCATION CODE <br />nn RTi7A('TnR 1 Sr-KVILt KrWUCJI Uri <br />REQUESTOR <br />Sr/R W KA WA KA <br />BIWNG PARTY <br />BUSINESS NAME <br />RA I '0 CHAN R� i/Ic <br />=PHONE W. <br />- v ©3 <br />MAILING ADDRESS <br />I F 4 - <br />F.0O <br />CITY SAA/ 4 , W ® <br />STATE 6. ZP -77 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acicicwtedge that au site andior protect specmc <br />Pueuc HEALTH SERVICES EWROWENTAL HEALTH OWicN hourly charges associated with this project or activity wdl be bleed to me or my business as identified on this ami. <br />I also certify that I have prepared this application and thathwork to be pe need wi done in accordance with all SAN JOAQUIN COUNTY Ceiinance Codes. Standards, STATE anc <br />FEDERAL laws. <br />APP�iucAw SIGNATURE: DATE: <br />PROPERTY / BUSINESS CWNER C OPERATOR /NtWGER Q OTHER AUTHCRmAGENT li3'_,J�PM�� �X O�jOJ? <br />If Aaw,-c wr a not tte 9(, Y,,G P proof of authoraadon to sign is mquaed ri t t e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release o' <br />any and all results, geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY Pueuc HEALTH SERvrC`s EwncNUE'<TAL HEALTH DIVISION as soor <br />as it is available and at the same time it is provided to me or my representative - <br />TYPE OF SERVICE REQUESTED: } CP 6 r O oA) 6) ro ll? �q4 E <br />COMMENTS: , p � � � 'n !1 n � � /Z S I J le- ( —� <br />l RECEIVE:F <br />OCT 3 1 �On� <br />SAN JOAQUIN COUt, , <br />PUBLIC HEALTH SERvglf'• <br />ENVIRONMENTAL <br />INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br />APPROVED BY: EIIPL^,1 r'f:C J-_ ( rJATG' <br />ASSIGNED TO: EmPLOYEE#:/� 3 DATE' <br />Date Service Completed (if already completed): SERVIcsCDDE: <br />Fee Amount' �"7Z- Amount Paid S = fn l� Payment Date / Q -3 ( 06 <br />Payment Type Invoice # Check # Received By: <br />