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}" - <br /> ypc of Business or Property SERVICE REQUEST <br /> FACILITY ID d SERVICE REQUEST A <br /> r OWNER 1 OPERATOR ��IJ��7 <br /> t <br /> 81 LING PAR '. <br /> FACIU[Y NAME F«Q tree It ` s <br /> SffEADDRESS aG �6� � �r�7(7V1 1600 CA � <br /> Str�etHu��r aGec9an <br /> Mailing Address (if Different from Site Address) sv..rN,m. <br /> Trw avh6 r ' <br /> CITY .� <br /> $TATE ZIP <br /> PHONE#1 EXT17 <br /> ., AP " <br /> LAND USE I�PLICAT� r� <br /> PHoxE#2 ; <br /> En. BOS:DIsTRICT <br /> LOCATION CODfi d <br /> REflUESTOR CONTRACTOR I SERVICE REQUESTOR <br /> Ll <br /> 13rLUHG PARTY O ' <br /> BUSINESS NAME �� <br /> MAILING <br /> l�� Yl � PHONE# <br /> 10� 7 <br /> MALINGADDRESS3� - 37011V <br />� ln <br /> FAN# <br /> G 20 333- <br /> STATE or ZIP J~p?q <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business Owner,operator or authorized agent of same,adnowledge that all site and/or pmjcct s�pedfic <br /> PUBLIC HEALTH SERHICES ENVIROWENTAL HEAL7H DIVISION hourly charges associated wilh this project or activity will be bined to ma or my business as identified an this torus. <br /> 11150 certify that I haaazm <br /> be performed vrrn be done in accordance with all SAN JOAQUaa COUHTY OrdinOncn Codes.Standards,5T ATE and <br /> FEDERAL taws. <br /> i <br /> APPUCAxT SIGIiATUR DATE: <br /> J.Ll� <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR I MANAGER 0 OTHER AUTHORILDAGENT <br /> IfArPur�wrisnotfturrr requirod rime <br /> 1I3L++'Si P .y�rvof of atrrhariraricn to si n is <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property bated at the above site address,hereby authorize the release of t <br /> any and all results,geolechnical data andlar environmentaVsite assessment information to the SAN JQACION COUNTY PUBLIC HEAL711 SLRvr Z-S E?mRoNwuTAL HEALTH DWION as anon <br /> as it is available and at the same fime it is provided to me or my representative. f <br /> TYPE OF SERvicis REQUESTED: ,{ [ <br /> COMMENTS: <br /> 6mgh fK51, �'acQlt �r`h <br /> GSr boy' , J��crJe <br /> INSPECTOR'S SIGNATURE: S1N <br /> (V/yhegw�j b �1VIG�S <br /> CONTRACTOR'S SIGNATURE: �ssfl��r�1SH5� DMS N <br /> APPROVED DY:. <br /> 1111111 .000 EMPLOYEE 9: y DATE: <br /> A551GxEo T0: �� EMPLOYEE#: s J f <br /> ;P4 3J-- DATE: <br /> ,"bale Service Completed (if already completed): _ <br /> SERVICE Cooc <br /> Fee Amount: a P f <br /> Amount Paid <br /> �'�,s_ PaymentDatc <br /> Payment.Type ✓ Invoice g Check 9 <br /> Received By: Z�v- <br />