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SERVIC UEST <br /> Ty of Bt:sines or rope CILITY ID# SERVICE REQUEST# <br /> ERI OPERATOR Y—'11 /1 , BILLING PARTY❑ <br /> FACILITY NAME ��1 lJ <br /> SRE,ADDRESS /J <br /> &md Numbw Dlreceon (.[.I / Nana Typa suaek <br /> Mailing Address (If Different from Site Address) , <br /> CITY STATE zip <br /> PHONE#1 aT APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ET. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REOUESTOR <br /> REOU TOR a BILLING PARTY <br /> BUSINESS NAM - PHONE 9 �- 033 <br /> • - r <br /> MAILING Aq6RESS FAx# <br /> CTnSTATE /i2 (�— <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 S7havprepa <br /> RON ENTAL HEALTH DIVISION hourly charges associated with this project or acfivq will be billed to me or my business as identified on this form. <br /> I also certify that this;3ppli pion and that th rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERALIawS. �JAPPLICANT SIGNA �I yn <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ✓" ' <br /> IfAPPtr; ismff 8wNc PAarv.pmfo/authorRallon fo signurequired Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaVSlte assessment infomlaton to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as H is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CooO <br /> SPU`0N�A-ESP HSE S10N <br /> ENNRUNM <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE- I -� <br /> )• <br /> ASSIGNEDTO: ' ` EMPLOYEE#: 2 DATE: 1 O <br /> Date Service Completed (if already completed): SERVICE CODE: ANP 1 E: no <br /> Fee Amount: , Amount Paid I 0 Payment Date l l_�a&_ C;D <br /> Payment Type C Invoice# Check# Received By: -Z L <br /> � V <br />