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SERVICE REQUEST • <br /> Type of Business or Property .v I ;FACILITY ID# SERVICE REQUEST# <br /> R r-�-r X I S C A- Lr-- FA- 0© 0 5q/ 6,'e0034649, <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> Q U t IC S-rm P INS P,- t IG F,1--S <br /> Facltm NAME <br /> SITEADDRESS S+ C N BIZ 0 le- G I- L t4 _ <br /> Z. 1 Street Number Direction street x 2 7�. Svtt�6 <br /> Mailing Address (If Different from Site Address) <br /> L 6-t E-: a-c,T-9-n F r,-t.sIL. ST'2E,L,1- <br /> CITY = STATE Z1PVL&0 C A- 39- <br /> PHONE#1 LX T• APN# IJWD USE APPLICATION# <br /> (Sro) (o S - S'0 0 <br /> PHONE#2 D;T• BOS;DISTRicT LOCATION CODE'. <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR `,/ BUNG PARTY <br /> I C 14 Ar FiiL W A LT-0 J.( <br /> BUSINESS NAME ` PHONE# Err.( "r0 r-( K-!, r...L ►�►�.�, , C - /G 3 11 - r Z <br /> MAILING ADDRESS FAX# <br /> 5, — <br /> CITY I I( STATE C Al ZIP S .A-G R A U^��-�r 0 <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 project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT C �� <br /> If Avert r wr is not the Bitm PARTY proof of authorization to slpn Is Murred 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/Site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENvIRoNM[NTAL 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: , j�7- <br /> COMMENTS: V <br /> PAYMENT <br /> RECEIVED <br /> JUN 3 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. - EMPLOYEE#: DATE: (p 3 d <br /> ASSIGNED TO: �• CA��)� �9 EMPLOYEE#: Q�t�u DATE: 3 A-3 <br /> Date Service Completed (if already completed): SERVICECODE: 'qb P I E:23 Ll f <br /> Fee Amount: 674) <br /> 0 <br /> Amount Paid :2 (o oD -7—Payment Date &131 , <br /> Payment Type Invoice#' Check 4 �� Received By: <br />