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r <br /> r <br /> • SERVICE REQUEST <br /> Test f Business o ro arty FACIL�Co() SERVICE REQUEST# <br /> -�L .5iL06 15-62Z <br /> OWN I OPERAT R BILLING PARTY! <br /> FACILITY NAME <br /> SITE ADDRESS <br /> J40-- Street Number t7ireclion fV ( a Type Suite# <br /> Mailing Address (If Different from Site Address) 1 t L e- <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEST ` 14 BILLING PARTY <br /> BUSINESS NAM PHONE# E.T• <br /> MAILING A S r FAX# <br /> CITY Sr zip <br /> BILLING ACKNOWLEDGEg NT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andlor project specific. <br /> PUBLIC HEALTH SERVICES ENV ON ENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this toren. <br /> I also ceitfy that I have p ared is ation and that th work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. ,YS <br /> ApPLIGANT SIGNATURE: K4vz�2 DATE: /// <br /> PROPERTY I BUSINESS OWNER 11 OPERATOR 1 MANAGER ❑ OTHER AUTHORIZED AGENT Ci <br /> 1fAPPucANr is not the BnL+NG PART} proof of authodtatton to sign is required Title <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 andlor envimnmentaUsite 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: U(& <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JAN 1 0 2001 <br /> SAN <br /> ENVIROW, . <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: LPr P.MPLOY'EE t �'sT C) DATE: <br /> ASSIGNED T0: 1 F ,rte, EMPLOYEE M -'129e? DATE: <br /> autqb Date Service Compiet (if alrea y completed): SERVICE CODE: G P,E: Z 71� <br /> Fee Amount: Amount Paid a� , (�© Payment Date J jp <br /> Payment Type Invoice# Check# C g Received Bytt4��— <br />