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SERVICE REQUEST <br /> [FACILITY <br /> e of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (� <br /> 0-0 <br /> NER/ OPE TOR <br /> ' CHECK if BILLING ADDRESS <br /> NAME <br /> SITE ADDRESS <br /> -33V%treet Number V -� / <br /> Street Name A/ 60� 0 <br /> HOME Of MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE zip <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> y�, 2 <br /> PHONEY EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> il <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PRONE# <br /> HOME or MAILING ADDRESS FAX If <br /> ) I <br /> CITY STATE zip <br /> BILLING ACIGNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> 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 prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> /.i,, 9-17-9? <br /> j <br /> APPLICANT'S SIGNATURE: (.0 X [.LL DATE: 9—/7 � JqQ <br /> o <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGERE AUTHO ED AGENT a .j, <br /> If APPLICANT iS not the BILLING PARTY proof of authorization to sign is required itle <br /> AUTHORIZATION TO RELEASE INFOWMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 1i —2 bDO C'COMMENTS: _ T <br /> RECEIVED <br /> ll AUG 16 <br /> SAN JOAOUIN COUNTY <br /> ENVIRO MENHEALTH EA SERVICES <br /> DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: t - I DATE: <br /> ASSIGNED TO: ki1 EMPLOYEE#: �� 3 DATE: <br /> Date Service Completed (if already CDmpletetl): i SERVICE CODE: O'j I PIE: � v <br /> Fee Amount: Amount Paid ILJ I Payment Date <br /> Payment Type I Receipt# Check# 4,O Received By: <br /> SRREQrev.dm 7/(/1999 <br /> �. 'Wr <br />