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SERVICE REQUEST <br /> T p OFBi in Use P port <br /> FACILITY ID# SERVICER QUEST# <br /> OWNER OPER T ` CHECKIIB14LINGAODRESS0 <br /> FACILITY N <br /> SITE DRESS <br /> �U a I Su'teW <br /> ttss TAS rsstl <br /> or MAI N ADORES If e t from Site Address <br /> DIQ ) 1 <br /> S TE ZIP <br /> CITY (]1-- <br /> ' EaT. APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> Lo <br /> — ERT BOS DISTRICT LOCATION CODE <br /> p NE#2 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RC-OUESTOR CHECK It BILLING ADDRESSD <br /> I - PHONEIf ���� Er T. <br /> F <br /> BUSINESS E t , <br /> HOME or MAILING ADDRESS <br /> / ZIP <br /> STATE <br /> CITY <br /> It I LING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges <br /> associated with this project or activity will be billed to into or illy business as identified on this form'. <br /> I also certify that I have prepared this application and dint the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F LDRAL law\. ` / <br /> APPLICANT'S SIGNATURE: / DATE: `L <br /> PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTHERAUTI RIZEDAGENT lit Title <br /> IfAPPLICINT is not t/le BILLING PdKTY.proof ofaothorization to sign is require) <br /> AIITITORIZATiON TO RET EASF, INFORMATION: VVIIen applicable, i, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geoteclmnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICCS ENVIRONMENTAL HEALTH DIVISION as soon OS it is available and <br /> at the same time it is provided to me or my representative. <br /> ii! I, � YN`t IViG <br /> TYPE OF SERVICE REQUESTED: <br /> T� <br /> COMMENTS: pep C1121JUV , <br /> PUBLIC HEALYH elf"®VISION <br /> ENVIRONMENTAL HET+ <br /> CONTRACTOR'S SIGNATURE: <br /> INSPECTOR'S SIGNATURE: �p <br /> EMPLOYEE#: OlA' DATE: <br /> APPROVED DY: � <br /> DATE: <br /> ASSIGNED TO: �I'l.� EMPLOYEE#: u <br /> SERVICE CODE: P 1 E: <br /> Date Servica Completed (if already completed): <br /> / <br /> Foo Amount: <br /> 3C i Amount Paid Payment Date i <br /> Receipt# Check # Received By: <br /> ayment Typ <br /> Pe P <br /> 7/1/1999 <br /> SRIU:01cvAoC <br />