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• SERVICE REQUEST <br /> of Busines or Property FACILITY ID# SERVICE REQUEST# <br /> _] <br /> O ERI OPERATO 400-t— BILLING PARTY 11 <br /> FACILITY N t&a <br /> SITE ADDRES /�//^/ <br /> ay- Street Numbx ectl <br /> nlron e[WAe Type Suite# <br /> Mailing ddress (If Different from Site Address) <br /> CITY STATE zip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#Z /� BOB DISTRICT LOCATION CODE <br /> 0 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQ E R BILLING PARTY{yam <br /> BUSIN / PHONE# Em <br /> MAu GAD ES i FAX# / <br /> -POCA <br /> CRY L STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner, operator of authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTI,SERVICES ENV NM H <br /> IVISION hourly 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 p pared applicationnd that the ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. `/ <br /> APPLICANT SIGNATURE: ` DATE: Z <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL TiSa0tfiat BXUNCPARTY.proofofauthonzadon to sign isrWired ifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above she address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaltslte 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: PAYMENT <br /> RECEIVED <br /> DEC 2 6 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC SRVICES <br /> ENVIRONMENTALLTH HEAL H CIV SIGN <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: C60 l DATE: <br /> ASSIGNED TO: aS�?6A^ I <br /> EMPLOYEE If: � � DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: i "10 PIE: -23 <br /> Fee Amount: c� Amount Paidw a !a f, 0 U Payment Date / OCA <br /> Payment Type Invoice# Check# j ICf Received By: / <br />