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• SERVICE REQUEST • <br /> EH0061SR revised 07/10/98 <br /> Type of Business or Prope erC�.9 L FACILIT5RMUE SERVICE REQUEST# ORGWNER I OPERATOR BILLING PARTYFACILITY NAME fSITE ADDRESS2(� 4o L.Ookxtl,s <br /> Street Numba alreNan Type SubepMailing Address (If Different from Site Address) <br /> CTrY Zipcs��PHONE#1 Er. APN# PLICATION#PHONE#2 EXrLOCATION CODECONTRACTOR I SER / <br /> REQDE$TDR rO T,L <br /> Z EBILLINGY❑ <br /> BUSINESS NAME 1 PHONE <br /> 1`2 Yi Ir�c'fUy-S �j <br /> MAILING ADDRESS S FAX# <br /> Lot (UC7T Y) <br /> CITY ' / STATE ZIP <br /> TUV� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned pr perty or buss ss owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRO MENTAL HEALTH VISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify that I have prepared this applicatio the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards,ST TE and FE AL laws. ! <br /> APPLICANT SIGNATURE: DATE: � Z CJ C ", <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR MANAGER ��`'p OTHER AUTHORIZED AGENT ❑ /�(� 0 <br /> IfA PUCAN is not the BILLING PARTY Proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFOR ATIO : When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and al resu s, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL T DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ex <br /> 1/i,1 rfil1 si-L <br /> COMMENTS SPECIAL CONDITIONS)OF APPROVAL El OTHER ❑ <br /> RECEIVFn <br /> DEC <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: I CONTRACTOR'S SIGNATURE: i DATE: <br /> I i <br /> APPROVED BY: EMPLOYEE#: ��� DATE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 3 Y7� P I E: 73 04- <br /> Fee Amount: (l7 Amount Paidf e ll� Payment Date <br /> Payment Type ( l Invoice# Check# <br /> 11a Received By: <br />