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• SERVICE REQUEST <br /> T of Business Pr perty FACILITY 10# SERVICE REQUEST# <br /> OW PE R BILLING PARTY❑ <br /> r <br /> FACILITY E - <br /> Sq II <br /> I fl�J <br /> Straal Number 04ecben TyOa sung[ <br /> Mailing Address (If Different frTfra Site Address <br /> `V <br /> Coy TE <br /> PMONE#1 �T• APN# - LAND USE APPLICATION# <br /> © a Qb� <br /> PXrJto n (� Exr. BOS DIST= LoCATax CODE <br /> . tJ� CONTRACTOR I SERVICE REQUESTOR <br /> REQUES BILLWG PARTY <br /> Bust P off # <br /> MAI DRESS6 FAX <br /> - 3y a- <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES E M TAL HEALTH DMSION hourly charges associated with this projector activity will be billed tome or my business as identified on this form. <br /> I also certify that I have prep red B app/ d Nat the work to be performed will be done in accordance with all SAN JOAanN COUNTY Orffinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANTSIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZED AGENT L <br /> YAPPLcwris not emB r�proorol authorization to sign is mqukvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operalorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geolechniat data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES F1MRoNMENTAL 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 REQUESTED: <br /> COMMENTS: <br /> r <br /> ri�Jc,:,IV;d IC iJNT <br /> u "JI� <br /> l •. ., -,!lona: <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:, U EMPLOYEE#: DATE: <br /> ASSIGNED TO: 8r. IEMPLOYEE#: !';`3 P'_"1 DATE: <br /> .Dale Service Completed (if already comple ed): SERVICECODE: _S C lqS PIE:.2308 <br /> Fee Amount: 7 oti Amount Paid -� ;L� Payment Date <br /> Payment Type ✓ Invoice# Check 1 J Received By: <br />