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look SERVICE REQUEST <br /> Type of Busin ss r pe FACILITY ID � � SERVICE REQ T� <br /> - I <br /> OWNER/ OPER*OR OR n 0 ` r ?)q CHECK If BILLING ADDRESS❑ <br /> 11 ' (fi, C'; <br /> a <br /> FACILITY NAME IN6t <br /> SITE ADDRESS <br /> 1�_ StISSS NII�LbSfC4fiL4 I9�I N�Te TYDR Suite <br /> HOME or MAILING ADDRESS (If Different from SIte Address) <br /> CITY STATE ZIP <br /> PHONE#1 FXT• APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOal I � CHECK If BILLING ADDRESS <br /> 1'L Pt E# EXT. <br /> BUSINESS NAME �/ �j lrj/� �• yy <br /> HOME Or MAILING ADDRESS / , <br /> YY� l O ��2 /) � <br /> CITY S gTE ZIP <br /> BILLING ACKiNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project specific PUBLIC IJEALTII SERVICES ENVIRONMENTAL I{EALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certif Tave premed thisplic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stanclart , STA// EDERAL aws. <br /> i�-IC i T S NATURE: � U� DATE: 7A <br /> PROPERTY/ BUSINESS OWNER OPERATOR/MANAGEROTHER AUTHORIZED AGEN74,�/r ') ' <br /> If APPLICANT is not the ilILLIIVG PARTY proof of authorization to sign is required Title <br /> A1JT110R17A1'10N TO RELEASE INFORMATION: Wltcn applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and 1 <br /> at the Same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: AN� . <br /> COMMENTS: REG��v <br /> �E)N/ en hw��a,LA <br /> Nov cooN� <br /> P pNCl�ENj P��'' <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: 1 EMPLOYEE#: DATE: 0 <br /> ASSIGNED TO: EMPLOYEE#: 2� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: ZVIZ <br /> Fee.Amount: ` / Amount Paid I i Payment Date l_0-1V�w <br /> Payment Type <br /> Receipt Check # Rocolved By: <br /> SRRI:c)rcv.Jac ^c �//� 7/1/1999 <br />