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SERVICE REQUEST <br /> Type sines orfrap rty ! FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 6ERATO BILLING PARTY❑ <br /> FACILITY N l <br /> SITEADDR£Ss <br /> �4 e4[Hui[rdfr Oirecean �SA mal N i <br /> TYPE Suk�1 <br /> Mailing Add r ss (IfANffe ent from Site Address) <br /> C d S A ZIP <br /> 7 <br /> / l�J <br /> P ONE#1 Exr. APN <br /> { j } �Lo L , r „ 3 LAND USE APPucATlarr# <br /> P �f#2 _ BOS DISTRICT LOCATION COPE: <br /> f 7 ff�_�LT. <br /> `�/y CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTO BILLING PARTY <br /> BU54NESSNA>aE L"� u G :�%�� PHoNt=,#A�L� <br /> hiEuLING ADD ESS <br /> } YZ - STATE zip <br /> — <br /> BILLING ACKNOWLEDG ,MPNT: 1, the undersigned property er business owner, operator or authorized agent of same, acknowledge that an site and/or project speafic <br /> PUBLic HEALTH SERVICES E1J4IRONUENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed to me or my business m identified on thls form. <br /> I also certify that I haveeparr fthis application an Ihat the work t be performed w"iil be done in accordance with all SAN JOACuiN Courrrr Qrdinanco Codes,Standaids,STATE andFEDERAL taws. f�/' / /c <br /> APPLICANT SIGNATURE: t °" �r Q <br /> DATE: <br /> PROPERTY I BUSINESS OWNER D OPERATOR IMANAGER ❑ OMERAUTHoRizcDAGENT <br /> If Avar_ccwr is nd the 04tp2P mr proof of aurhoriratfon to sign h roquirod Ti lla <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geolechnical data and/or environmentallsile assessment information la the SAN JOAGUIN COUNTY PUDLIC HEALTIi 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: �f <br /> INSPECTOR'S SIGNATURE; CONTRACTOR'S SIGNATURE: <br /> APPROVED t3Y:, EMPLOYEE 9: � DATE: <br /> Z <br /> ASSIGNED TO:,iMPLOYEE °; j DATE: <br /> `J OO <br /> Date Service Compl ed (if already completed): SERVICE CODE: �' P i Era -7,0 <br /> Fec Amount: TO Amount Paid <br /> �vl "-j �— Payment Date <br /> Payment Type ✓ invoice#" Check# —10 <br /> Received Byr—�— <br />