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SERVICE REQUEST <br /> Type of Business of Property ITY ID N TSERVICE REQUEST <br /> 0 �tj BILLING PARTY ID <br /> OWNER I OPERATOR <br /> FACILITY NAME <br /> SITE ADDRESS <br /> o 3 Tp. S.M I <br /> Mailing Address.0f Different from Silo Address) <br /> CITY STATI� zip <br /> --J�LAHiO USE APPLICAIJON 0 <br /> PHONE#1 <br /> PHONE#2 bu�DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOS <br /> REQuESTOR BILLING PARTY 0 <br /> BUSINESS NAME PHONE# <br /> MAILING ADDRES S FAX <br /> CITY STATE Zip <br /> BILLING ACKNOWLEDGEME 1, the undersigned property or busimuni owner, aparalor or authorized agent of same. acknowledge that all site andlof project specific <br /> PUBLIC MEkLTH SERvas ENVIRONMENTAL HEALTH DIvISION hourly charges associated with this project or activity rill be billed to rrHt of my business as identified on this low <br /> I also certity that I have prepared this application and that the work to be performed will be done 0 accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL IdW5. <br /> APPUCANT SIGNATURE: J� <br /> V <br /> PROPERTY/BUSINESS OWNER D OPERATOR/MANAGER 0 O[HERAUrHORIZEDAGEN.T 0 <br /> #A�rjS0"B&1MpM Tirld <br /> AUTHORIZATION TO RELEASE INFORMATIO :When applicable,1.the omer or oporalfirof the property located at the above site address,hereby authorize(he release of <br /> any and all results,geotechnical data and/or efivirummeinallsile assessment into moon to the SANJOAGUN COUNTY PUBLIC HEALTH SEROCES ENVIRONMENTAL HEALIH DIVISION as Soon <br /> as it is available and at the same orne it is pmvided to me or my repre5emadve. <br /> TYPE OF SERvicE REQUESTED: <br /> CoMmEnns: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: --FUL� DATE; <br /> ASSIGNEDIO: DATE: '(7 <br /> Dale Se"Ice Completed ffalready completed): 1 40 ERVICE CODC j�t P I E; <br /> Fee Amount: tP6 payment Date <br /> Payment Type I ra iv Check 4 TfIeCplyed By. <br /> J� <br />