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SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID SERVICE REQUEST # <br /> OWNER OPERATOR <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAME <br /> /5a <br /> SITE ADDRESS qq <br /> I / � ' SttSSiNS14LbSL�D1r91it14fL IQSL�R24 _ I Sy to 0 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE zip <br /> �tS 4 <br /> PHONE 91 Ex T. qPN# LAND USE APPLICATION# <br /> (,to 7) 36 — 73 75 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> i <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> PHONE# — ExT. <br /> BUSINESS NAME <br /> (e33 I <br /> HOME or MAILING ADDRESS FAX , <br /> X535 (209 ) <br /> CITY STATE ZIP <br /> ' � <br /> 952-o,5 <br /> 1311,LING aC MNONVLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of salve, <br /> acknowledge that all site and/or project specific PUBLIC IIFALTii SERVICES ENVIRONMFNTAL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this fornt. <br /> I also certify that I have prepared thinapliCation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> oUN I'Y Ordinance Codes,StandardATE and FEDERAL s. <br /> APPLICAiVT'S SIGNATURE: - DATE: 9 5 <br /> ROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTIIER AUTHORIZED AGENT <br /> if APPLIC-INT is not the(3tLLlNGPARTY,proof of authorization to sigtt is required Tittr <br /> AUT110R17ATION TO RELEASE INFORMATION: When 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 /> intbrmation to the SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED 13Y: EMPLOYEE DATE: <br /> #: /c�cro�� <br /> + ASSIGNED TO: EMPLOYEE#: 2 DATE: <br /> Date Service Complotod (if alread ompieted): SERVICE CODE: TP,E:Z� <br /> C <br /> FloAmount: X3 ©� Amount Paid �3 4d Paymant DateC�ment Type Receipt aX Cheek Received By: <br /> 7/1/1999 <br /> SRIZE01cv doc <br />