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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 2.ftA L 5� 00, <br /> OWNER I OPERATOR BILLt G PARTY❑ <br /> E AIA ✓A2RA A)AvArc-ie-/-\ -p <br /> FACILITY NAME <br /> 1 .EG-OA(TV17P,/,4 e- <br /> SITEADDRESs CA 2m,51—o �✓� <br /> StrtelNumtur WresGon strMN&MI YYPe Sulu! <br /> Mailing Address (If Different from Site Address) <br /> CITY -7-1z-ASTATE Zip <br /> � � s 376 <br /> PHONE#i APN# LJWD USE APPL3CAvoN# <br /> PHONE#2 ear. BQS.DISTRICT r . <br /> LOCATION CODE: <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> 17o/'jap�S NE <br /> BUSINESS NAME PHONE# f FJcr. <br /> {r A L L E A <br /> MAILING ADDRESS FAX# <br /> F0 , L�OX 37?� 66 - Z�IFj <br /> CrrY <br /> fZ /—O C!C STATE CA <br /> Zip <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 projector activity will be billed to me army business as identified on this loam. <br /> I also certify that I have prepared this Ii tion anAthbe performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPUCANT SIGNATURE: DATE; <br /> PROPERTY!BUSINESS OWNER 0 OPERATOR!MANAGER ❑ OTHERAUTHORILEDAGENT <br /> frArvr . isnotV proalaraufhorizatlonrosign$raqu T1Ne <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,l•/lie owner or operator of the property located at the above Sita address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmcntallsite assessment information to the SAN JOAGM COUNTY PUDLIC HEALTH SERVICES ENVIRONMENTAL 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: A(!' T/�-A T-tt-7 LOA W ./v`(2 -'�-7uP E E <br /> tAl <br /> COMMENTS: <br /> PAY ME 40 <br /> RECEI Er <br /> � �s28 02 <br /> SAN JUAUUIN Ui.IUN rY <br /> PLSUC HEALTH SERVICES <br /> E4t4.1PiCT MENTAL HEALTH DIVISIUI. <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGTURE: <br /> APPROVED DY:. ' NAEMPLOYEE#: c9a-) ( DATE: <br /> ASSfGNED-TO: <br /> EMPLOYEE#: � � � Q .DATE: <br /> Date Service Com feted (if already completed): C- <br /> St RviCE CGDE: `– PIE: <br /> Fee Amount: ?fl(�� Amount Paid <br /> ��- �� Payment Date 15 & ") 0 <br /> Payment Type Invoice 9* Check# p <br /> 7p � Received By: <br /> t <br />