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iSERVICE REQUEST <br /> Typ,�.O Business or Property FACILITY ID# SERVICE REQUEST# <br /> (!!!!!} PERATOR BILLING PARTY <br /> VV <br /> FACILITY NAME <br /> SITE ADDRESS sac ��a <br /> 0—�; Streel Number Diredawn SUM Name Type svitep <br /> Mailing Address �(Irf Different from Site Address) <br /> cT--rt t. -+— <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> " 3-I?6 k-3 <br /> PHONE#2 EBT. BOS DISTRICT LOCATION.CODE <br /> CON CTO /SERVICE REQUESTOR <br /> REQUESTOR QG BILLING PARTY❑ <br /> IKF— <br /> BUSINESS NAME /' r� PHONE# / pT _ �• <br /> c–•'i OG�Sla� ��(t-l!IC.Q- �7�19TId� J�JQ.. LC3� b '"O c� -� <br /> MAI LING ADD RE FAX# ` ' <br /> rn S* ZIP- SZl3 <br /> c <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned oparty or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEA DIVISION h ury Charges associated with this project or activity will be billed to me or my business as Identified on this form. <br /> I also certify that I have pare licati Ian be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGEE?/' <br /> OTHER AUTHORIZED AGENT ❑ <br /> IfAPw.cANriswtft8nuN Pm proolofauthorization 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,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC 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: <br /> COMMENTS: yak. <br /> EN,p <br /> JAN 2 91999 <br /> SHB.,JG.kJIAN OOUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMF.NrAL HEALTH CIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> nPFROL'EDSY: EMPLDYCC il; /"'-`p'yT� B1ATE; <br /> it <br /> ASSIGNED TO: EMPLOYEE#:(/l D DATE: <br /> Date Service Completed (if already mpleted): SERVICE CODE: P I E: <br /> Fee Amount: h too Amount Paid -'x ay( <br /> 36 Payment Date <br /> Payment Type Invoice# Check# I p2l Received By: <br />