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IL <br /> SERVICE REQUEST <br /> Ty f EEsiness or Pr petty FACILITY ID# SERVICE REQUEST# <br /> ! <br /> OWN I OPERATORIY � BILLI G PARTY <br /> FACILITY NAME <br /> SITEADDRESS <br /> StreetNumuer oirectfon � � Na Type Suite <br /> Mailing Address (If 6ifferent from Site Address) ,f} <br /> C L STATE <br /> PHLI E#1 Ex-r. ARN# LAND USE APPLICATION# <br /> Er. �� $OS DISTRICT LOCATION CODE <br /> P ,UI 3�3 � S' � / <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQU TO SICCING PARTYY_J <br /> &j!2 <br /> BUSIN S NAME PHONE# T <br /> /- , <br /> MAILING ADDR ��' FAX# <br /> i I <br /> CITY rSTATE ZIP <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 SE=RVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with This project or activity will be billed to me or my business as Identified on this form. <br /> also certify that I have pre red 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 r _ <br /> APPLICANT SIGNATURE: iPk DATE: <br /> PROPERTY i BUSINESS OWNER 171 OPERATOR!MANAGER 11 OTHER AUTHORIZED AGENT <br /> If APPUCaxr is not the BiujNc PARry,proof of authorization to sign is required Ti tie <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,geotechnical data andfor environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRCNMENTAL HEALTH DIVISION as soon <br /> as if is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: r r <br /> COMMENTS: RECEIVED <br /> FREUB172a <br /> Sf.N JOAQUIN CIUUN ry <br /> PUBLIC HEALTH SERVICES <br /> "E VIIIIINMF_NTAL HEALTH DIVISIGr <br /> INSPECTOR'S SIGNATURE: CONTRACTOR's SIGNATURE: <br /> Are O EDGY: EMPLOYEE: C cc DATE- <br /> Ass IGNED <br /> ATE-ASSIGNED TO: �y�tY'Z�J7 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' PIE: <br /> Fee Amount: "0 Amount Paid , 3 r Payment Date .?-11_7 1 n <br /> y <br /> Payment Type Invoice# Check—# / I Received By: " <br />