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10 t He_ ti‘ co 14 /t3 I 114 u Axee <br />(eh./ — S HA. <br />SERVICE REQUEST <br />EH0061SR revised 09/04/98 <br />I Type of Business or Property I 1 _ FACILITY ID # SERVICE RE_QUEST,# ,---- <br />____ 1 OWNER I OPERATOR '..-\,,....v\i‘... <br />C— .„.'-i-71/\/ <br />BILLING PARTY III <br />FACILITY NAME f <br />7A-OLLOACI <br />SITE ADDRESS ---r- pmf4,1 <br />Street Number L <br />gLVO <br />Direction <br />,1•All‘t C Street Name Type Suite # <br />1 Mailing Address (If Different from Site Address) <br />Crrr STATE ZIP <br />1 i t 1 PHONE .-.- . E . <br />941, ,(n (6(Lf <br />APN # LAND USE APPLICATION # <br />5/A) / LVILPI_PCADC-q- - <br />PHONE #2 EXT. PHONE <br />(7,10 (3(-*(1-C--17 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR 1 SERVICE REQUESTOR <br />- REQUESTOR <br />Mt 14-f7,0 To BILLING PARTY <br />BUSINESS NAME n _ <br />(LA-----TIQ ( (I0 L c --(AA-C <br />PHONE # <br />(g0 % (/ k <br />EXT. <br />9 <br />MAILING ADDRESS_ <br />( ya) 5, CAltratecc <br />c <br />L-120 <br />FAX # <br />Crrr ( To 0 STATE <br />C44— <br />ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br />me or my business as identified on t <br />I also certify that I have prepared this plication and that t work to be performed will be done in accordance with all SAN JOAQUiN COUNTY <br />Ordinance Codes, Standards, STATE a la <br />APPLICANT SIGNATURE: <br /> <br />DATE: /i 6 <br />PROPERTY! BUSINESS OWNE OPERATOR / MANAGER OTHER AUTHORIZED AGENT ' <br /> <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, <br />hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: po 0 <br />\PI Lek VI C <br />OTHER COMMENTS II SPECIAL CONDMON(S) OF APPROVAL 111 III <br />PAY R4 E NI <br />OCT 6 1998 <br />„RI, .n.),,,Quk uuuNr, <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAi l-i! Ai I I; DIVISioN <br />INSPECTOR'S SIGNATURE: i CONTRACTOR'S SIGNATURE: <br />i <br />! DATE: <br />EMPLOYEE #: 0 6 0 t DATE: t',4„. 7 98 APPROVED BY:'-- vv,...e9,c,) 0, , k v... J., <br />ASSIGNED TO: i24_{.1./...Q. <br />Ut.-NN-C4.- ?\(\ <br />EMPLOYEE #: f ) Lt Cri DATE: <br />Date Service Completed (if already completed): SERVICE CODE: -5 D- -5 PIE: 36 <br />Amount Paid 31 ,10.00 Payment Date 0-- [ -6 ) Fee Amount: D__0-(1) - <br />Payment Type Invoice # [Check # IIII,.--(7 Received By: