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SERVICE REQUEST <br />Type of Business or Property FACILITY ID II SERVICE REQUEST ~ <br />C!J/9 (7'1 <br />OWIIER I OPERATOR BILlIlIG PARTY CJ. <br />FAclLm NAME c:::-:::::.II /.~/7 IN ~~~S ~a VlQ)<:ij)~./11 '-A-11\r-.>; <br />SirE ADDRESS <br />Slrtt'Humo ••l I -l'V\('\~~m.I IOI,tc1Ion y r,P'SUitt' <br />Mailing Address (If Different from Site Address, <br />Cm C I {STATE Cfr-liPYTDI!I~ <br />PHONE #1 Ext.I APN#llANo USE APPLICATION # <br />() <br />PHO/jE #2 Ext.I BO~DIS~R/cT -I LOCATION C~DE <br />().. <br />CONTRACTOR I SERVICE REQUESTOR <br />REQIIFSTOR <br />BUSINESS NAME <br />MAlu/IG ADDRESS <br />Cm STATE C r/T <br />BILLING ACKNOWLEDGEMENT:I.tile undersigned property or business owner,operator or authortred 3g8nl of same.aclcnowledge that all site andlor project specfic <br />PUBLIC HEAlTH SERVICES ErN/ROOME/HAl HEAl.TH DIVISION hourly charge!associated wilh tills project or activity wiU be billed 10 me or my business as identified on lIlis lorm. <br />I also certify lhall have prepared tIlis oimed wiIllle done in accordance wilh all SAN JoAQUIN coosrr Ordinance Codes.Standards,STATE and <br />F=OERAlla~.5--1 e-f 9DATE:.,-----''--....:.....(_APPUCANT SIGHATURE:__+.Q.....=.._r-~--------------------- <br />PROPERTY I BUSINESS OwNER 0 OPERATORI MANAGER 0 OrnER AlJ1l-lOflIZED AGENT 0 _ <br />/I ~rl$lIOithrJ8um/'AJja proof of.u/horlulion /0 sign Is requlnd Tille <br />AUTHORIZATION TO RELEASE INFORMATION:When applicable.I.tile owner or operator ot lhe property located allhe above site address,hereby authorize Ihe release o( <br />any and all results.geoted1nical data andlor envlronmentaVsile assess men I Into rnadon 10 tile SAtI JOAOUUj COUNTY PuBLIC HEAlTH SERVICES ENVIRONMENTAl HEALTH OrvlSION as soon <br />as Ills available and at Ule same time It is provided 10 me or my representa!lve. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />PAY E'p r="'':1\II';1M' <br />IMN .JOAb\JIN ~bUN"'yPUBUCHEALTHRVIO <br />fNvtAONMENTAt.HEAlTH DIVI ItJ~ <br />INSPECTOR'S SIGNATURE:CONTRACTOR'S SIGIIATURE: <br />Fee Amount:70 Amount Paid :1 <br />Check /I of 5/ <br />APPROVED BY:EMPLOYEE II:c.;;[J)\DATE: <br />AsSIGNED TO:EMPLOYEE II: <br />Dale Service Completed <br />Payment Type