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SERVICE REQUEST 0 <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />R CTA I L (, A, s k I- f ,-t E. <br />PHONE # <br />j=A4 0000 &-77-40 <br />R DO 34t147 <br />OWNER I OPERATOR <br />BILLING PARTY 0 <br />Q U I V- S T O P ►M At -r, fL ET S <br />FACILITY NAME <br />QUtI� 4f' Or /c(?, <br />JUN 3 2003 <br />SITE ADDRESS <br />W_ <br />L o c is F o fz d S T. <br />3 4 <br />CITY S a.0 n_ A tM F 0 <br />STATE CA <br />Z 0 S Stott Number <br />Direction <br />su'W Hame <br />INSPECTOR'S SIGNA RE: <br />Type <br />SUHa t <br />Mailing Address (If Different from Site Address) <br />#: L' (11 V 9 <br />1-/S 6'� E V.t.'TF- R P rL S I� <br />S T- 2 Firt/r <br />ASSIGNED T0: 4/ CD�—�� <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />USE APPLICATION # <br />, I e, P I E: 3 <br />7—AND <br />Amount Paid Z (0 700 Payment Date + <br />PHONE #2 EXT•BOS:D[STRICT <br />( <br />_7 <br />Payment Type I,--, <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />C 0 AP— L f <br />BILLING PARTY <br />BUSINESS NAME � <br />PHONE # <br />EXT. <br />PAYMENT <br />MAILING ADDRESS O, 0 v ` O Z T— <br />FAX # <br />JUN 3 2003 <br />/� <br />Clic <br />3 4 <br />CITY S a.0 n_ A tM F 0 <br />STATE CA <br />ZIP r/ S6 9 <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 projector activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application <br />FEDERAL laws. <br />APPLICANT SIGNATURE: <br />that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />DATE: `i/q, / o 3 <br />PROPERTY I BUSINESS OWNER 0 OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT : C 0 #J -T- R A --C 0 A— <br />IfAPftr-wr is not the BN La+c Purry proof of authorizatlon to sign 1s requfrod 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 environmental/sile assessment information to the SAN JOAQUIN COUNTY Pu©uc 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 />COMMENTS: <br />PAYMENT <br />RECEIVED <br />JUN 3 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNA RE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:,E6tPLOYEE <br />#: L' (11 V 9 <br />ATE: <br />%l/ <br />ASSIGNED T0: 4/ CD�—�� <br />EMPLOYEE #: U 9,f <br />DATE: <br />(3 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />, I e, P I E: 3 <br />Fee Amount: '2)(,700 <br />Amount Paid Z (0 700 Payment Date + <br />Payment Type I,--, <br />Invoice #' <br />Check 4 �3 2-6 V,�— <br />Received By: i <br />