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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST It <br /> 5 (�0o23o3So <br /> OWNER OPERATOR BILLING PARTY 0 <br /> FACILITY NAME i6 <br /> SREADDRESS l t/'/�--•V � <br /> �+" $trot Humlat [� $4MNam Suet <br /> Mailing Address (If Different from Site Address) <br /> CRY STATE zip <br /> PHONE#1 (J{/ Ea• APN# LAND USE Appur;ATI0N9 <br /> ( ) <br /> .PHONE#2 ,EAT. BOS LsiRICf _ LOCATgN 000E <br /> CONTRACTOR I SERVICE REQUESTOR <br /> PhWLINGADDRESS' <br /> BALING PARTY <br /> d <br /> PHONE# rAr. <br /> 11��,�, '/ ''9(i STATE <br /> /-I ZIP <br /> 9sa0s <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andfor project spearic <br /> PUBLIC HEALTH SERVICES 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 /> I also cenity,that I have prepared this application and that the work to be peno will done in accordance with all SAN JOAOUW COUNTY Ordrnancg Codes,Standards,STATE and <br /> FEDERAL laws. <br /> /� <br /> PLICANT SIGNATURE: DATE: D� (/U�II� <br /> PROPERTY IBUSWESS OWNER ❑ OPERATOR/A1A,VAGFR ❑ OTNERAUTHORIZED AGENT 0 <br /> PAwtAiNris nor am ,norm.PAS p, jorauNoriaadon to sign is r q,i d ruo <br /> AUTHORIZATION TO RELEASE INFORMATION;When applicable,I,the owner or operator of the property b <br /> any and all resultsgCOICLhoated at the shove site address,hereby authorize the rebase of <br /> , filWl data and/or CRVirenmentaVSilC aSSes"nent Infonnati.n b the SAN JOAQUIN COUNTY PUBLIC HEALTH SERvICEs ENVIRONMENTAL HEALTH DNISION as soon <br /> as it is available and at the same lime it is provided 10 me or my representative. <br /> TYPE OF SERVICE REQUESTED: ccy <br /> COMMENTS: Q� <br /> JUN B Zfflo <br /> • FN EUBL C H--',,UIN COUNTY <br /> VIP,ONMEnTALLHEALTH ICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. 'T` <br /> EMPLOYEE I}: �� I DATE: <br /> -ASSIGNEDTO: ` rl EMPLOYEEM 3 <br /> O <br /> Date SDATE: <br /> ervice Completed (it - � :,. <br /> SERVICE COOE: `• .� - •P I E:. . <br /> Fee Amount: � Amount Paid <br /> Payment T c Payment Oat. <br /> YP Invoice 9, Check lR2 P <br /> ',J(i 3S Received By: <br />