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SERVICE REQUEST <br /> Type of Business or Prope ] FACILITY 10# SERVICE REQUEST# <br /> 1 -F" (IC00clL43 �0171 <br /> OWNER I OPERATOR BILLING PARTY L7 <br /> 6211h ne'l - <br /> FACILITY NAME <br /> SITE ADDRESS <br /> s! S �/ //—� Street Number DiredonIL ame Type _ SuiieO <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLtwiON# <br /> ( ) <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR / <br /> �2, r BILLING PARTY <br /> BU IWE55 NAM ` PHONE# , Exr. <br /> MAILING ADDRi FAX# <br /> CITY 'j STATE 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 SERVICES ENVIRONMENTAL HEALTH DIVISION hourty 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 pre argd t application and that the work to be performed will be done in a=rdance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. I <br /> � 1-0 <br /> h��JJ �j J DATE:APPLICANT SIGA r <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER Q OTHER AUTHORIZED AGENT IY <br /> if APPuCANT is rat the 8IU)NGPARrv,proof of authorisation 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 and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it Is avalfable and at the same time it fs provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ;n f <br /> COMMENTS: <br /> J RE <br /> SAty,70��P�SER�t��V1StCsri <br /> ��VIR NPfi�S P�HE� <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: E"tPLOYEE#: DATE; { �1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> I <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid O� L! Payment Date <br /> Payment Type Invoice 9 Check# Received By: <br />