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r • • <br />SERVICE REQUEST <br />LUN 1 KAG 1 UK 1 OCKVII r- KCLYCa"vn <br />BILLING PARTY <br />REQUESTOR <br />1 C 4 A-IiA— LAI jN, L _T ->Imo( <br />PHONE# <br />BUSINESS NAME <br />I 9"4; '3 '�- 3 •' % t,1' %— <br />FAX # <br />MAIUNADDRESS <br />G <br />Cm '�{ f L A vv- Fig "j�-p STATE C A, ZIP 9 S 6 i <br />BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or protect speamc <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges assacated w th this projector activity win be billed to me or my business as Identified on this form. <br />I also certify that I have prepared this applica . and that the work to be performed wln be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes. Standards. STATE and <br />FEDERAL laws. J <br />� / (d ( 0 2. <br />APPLICANT SIGNATURE' DATE'�d( <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER ALTfHORREDAGENT Vel: Title <br />If APAUCJxr is Wit &A SLOG Pka►r proof of sudmrastion to sign is nqubad <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. G the owner or operator of the property boated at the above site address, hereby authorize the release of <br />any and aU resufLs, geotechnical data and/or emironmentatlsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON MENTAL HEALTH DMSION as soon <br />... w..........e u...e :+rc nrrr.erlari M mn t1r my le�rPSentahVe. - <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />DAN JO AQNO� A V � gjOIS <br />O <br />pN6l1GE 1 \00" <br />p�V1R�NM <br />INSPECTOR'S SIG RE: <br />CONTRACTOR'S SIGNATURE: <br />F-VPLCM#: DATE' <br />APPROVED BY: <br />ASSIGNED T0: <br />EMPLOYEE#: g 3 I ?-- DATE: <br />Date Service Completed cif already completed): <br />SERVICE CODE: e C_ (.19 (C, <br />Fee Amount: Co '? c o Amount Paid Payment Date <br />Payment Type L <br />Invoice # <br />Check # 3 --�- • ( <br />Received By: � <br />