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SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> - BILLING PARTY❑ <br /> OWNER OPERATOR <br /> FACILITY NAME <br /> SITE ADDRESS sNme Tyoa sutra: <br /> Strew Numtrer Oirec:an <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> CITY <br /> Ezr APN# LAND USE APPLICATION# <br /> PHaNE#1 <br /> ( ) LOCATION CODE <br /> PHONE#2 CIT. BOS DISTRICT <br /> CONTRACTOR I SERVICE REOUESTOR <br /> BIwNG PARTY❑ <br /> REQUESTOR <br /> PHONE; ' <br /> BUSINESS NAME <br /> FAx# <br /> MAILING ADDRESS <br /> STATE ZIP <br /> CITY <br /> BILLING ACKNOWLEDGEMENT: h the undersigned property or business owner,operator or authorized agent of same,acimowledge that all site and/or pmject specific <br /> P—t HEALTH SERVICES ENVIKC --TAI HEALTH DIvIsICN hourly charges associated with this PICiect or actrvny vnll be billed to me or my business as identified on This farm. <br /> 1 also certify that I have prepared this appliiceCon and that the work to he performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> DATE: <br /> APPLICANT SIGNATURE: <br /> CP,RATOftI MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> PROPERTY I BUSINESS OWNER ❑ Title <br /> 1(APavM a rrotthe 8��proo/oraudrormtlur to sign b raquvd <br /> ed at he <br /> ve site address,hereby authorize <br /> AUTHORIZATIDN�O�RhnLceC ASE aNFO �O Vsde assWhen plessmleni the owner <br /> m thor e SAN JOA uw COUNTY Prator of the property u SUC HEALTH SERACES ENNIRONMFMAI HEAL H DMSON as soothe release n <br /> any and all results,9 <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CONTRACTORS SIGNATURE: <br /> INSPECTORS SIGNATURE: DATE. <br /> EMPLOY�rf: ' <br /> APPROVED BY: <br /> EMPLOYEE#'. DATE <br /> ASSIGNED TO: <br /> SEIMCE COOE7 'P I E - <br /> Date Service Completed ('d already completed): <br /> - -� - <br /> Amount Paid Payment Date <br /> Fee Amount <br /> Payment Type Invoice# <br /> Check# Received By: <br />