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v SERVICE REQUEST ti <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C � dog <br /> OWNER OPERATOR BILLING PARTY❑ <br /> FACILITY NAME / <br /> SITE ADDRESS 1q 'Tf�I{-(,t. /�t� IVr^�\/�• <br /> v So aMNw&ar I) n `' 'v�.� -70drt Xain� Tm Sub/ <br /> Mailing Address (If Different from Site Address) <br /> CRY STATE LP - <br /> PHONE#1 EXT. APN# LAND USE APPLICATION <br /> ( ) <br /> PHONE#2 EXIT. BOS DISTRICT LW.:ATgN CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BUM PARTY.0 <br /> +r C-6 <br /> BUSINESS NAIVE �� P NE# 2-3 <br /> MAILING ADDRESS ,/f I FAX# <br /> CITY STATE /'f,J LP SZa <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or actively 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 COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. �� i' <br /> APPLICANT SIGNATURE: AT�i`7 t,— DATE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER Cl OTHER AUTHOmmo AGENT ❑ <br /> If APPucAvrisnotthe Bnu+cPum.Proof ofsudwizadon to sign Is mquaad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property kxeted at the above site address,hereby authorize the release of <br /> any and all results.geotechnical data and/or environmentallsite assessment infor Caton to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it's provided to me or my representative. <br /> TYPE OF SERVICE REQUESTEDL! T— C—,(b tk/v T- P I W///vf`-'lC/� n <br /> COMMENTS: I <br /> PAYMENT <br /> IFCFiVED <br /> OCT 121 ,9 <br /> "140 PUBLICAQDIN GOUN7Y <br /> HEALTH ES <br /> ENVIRONMENTAL HEALTH DIVISION. <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE If: nU I DATE: <br /> ASSIGNED TO: EMPLOYEE#: U Q �J DATE: <br /> Date Service Completed (if already completed): 1 SERVICE CODE: 3 PIE: <br /> Fee Amount: Amount Paid - - Payment Date _ <br /> Payment Type Invoice#' Check# Received By. <br />