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SERVICE REQUEST <br />Type of Business pr Property0�, ,r � <br />FACILITY ID 4SERVICE <br />REGUEST # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS D <br />FACILITY NAME <br />Ext. <br />7 <br />SITE ADDRESS <br />! <br />I <br />J' 0 5 SlrssJNl14Lb1' n1C4SL <br />I34I Nl e True <br />Suite +t <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />' <br />STATE ZIP <br />( 0 <br />PHONE fit EXT. <br />APN # <br />ZIP S� O <br />LAND USE APPLICATION # <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED 6' <br />PHONE #2 EXT. <br />DATE: <br />SOS DISTRICT <br />LOCATION CODE <br />DATE: <br />Date Service Complofod (i already completed): SERVICE CODE:' <br />` P I E: <br />� <br />Fee Amount: ) d`% <br />rnNTRACTnR / SERVICE REQUESTOR <br />RE-QUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />Ext. <br />7 <br />.,z 0 <br />HOME or MAILING ADDRESS <br />FAX fi <br />3 <br />3 �5- <br />AN JOAQUIN C 01LIN : Y <br />CITY <br />STATE <br />ZIP S� O <br />BILLING ING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific PUBLIC II[iAl_TH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br />associated with this project or activity will be billed to ine or my business as identified on this forum. <br />I also certify that I have prepared thi application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standa i , STATE and FEPf RAL laws <br />q <br />APPLICANT'S SIGNA-TURE: at n DATE: C// -'z F <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER OTHER AUTIIORIZED AGENT <br />If APPLIC.aNT is not the 9!LLfNG PARTY. proof of authorization to sign is required Title <br />A1JT1101UZ 1'10N TQ RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geoteelTnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IfEALTH DIVISION as soon as it is available and <br />7/1/1999 <br />TYPE OF SERVICE REQUESTED:4. <br />COMMENTS: <br />SEP 28 M9 <br />AN JOAQUIN C 01LIN : Y <br />PUBLIC HEAL64 SERVICES <br />ENVIRONMENTAL HE:ACfH UIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED 6' <br />EMPLOYEE #: CUL1 ' <br />\ <br />DATE: <br />ASSIGNED TO: �/ 1� /�Q .i <br />C <br />EMPLOYEE #: <br />DATE: <br />Date Service Complofod (i already completed): SERVICE CODE:' <br />` P I E: <br />� <br />Fee Amount: ) d`% <br />Amount Paid'K� 'N <br />Payment Date <br />Payment Type <br />Receipt # <br />Check tf/3S �� <br />Recolved By. <br />7/1/1999 <br />